Provider Demographics
NPI:1215622352
Name:WILSON, DAFEIONTHAY
Entity type:Individual
Prefix:
First Name:DAFEIONTHAY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19939 CHASEWOOD PARK DR APT 8215
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-1160
Mailing Address - Country:US
Mailing Address - Phone:281-408-0984
Mailing Address - Fax:
Practice Address - Street 1:19939 CHASEWOOD PARK DR APT 8215
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-1160
Practice Address - Country:US
Practice Address - Phone:281-408-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBACB917412106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician