Provider Demographics
NPI:1154429348
Name:WILSON, DONALD LESTER JR (PHD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LESTER
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 WEST SUPERIOR STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1017
Mailing Address - Country:US
Mailing Address - Phone:260-615-1173
Mailing Address - Fax:260-460-1481
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:VA NIHCS
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:260-460-1481
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041034A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling