Provider Demographics
NPI:1215990825
Name:WILSON, DELORIA R (PHD)
Entity type:Individual
Prefix:DR
First Name:DELORIA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6502 MISSION HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-1506
Mailing Address - Country:US
Mailing Address - Phone:210-662-8472
Mailing Address - Fax:
Practice Address - Street 1:1985 1ST ST W
Practice Address - Street 2:
Practice Address - City:RANDOLPH A F B
Practice Address - State:TX
Practice Address - Zip Code:78150-4314
Practice Address - Country:US
Practice Address - Phone:210-652-2448
Practice Address - Fax:210-652-3178
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1243103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling