Provider Demographics
NPI:1326664079
Name:WILSON, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14615 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2027
Mailing Address - Country:US
Mailing Address - Phone:773-332-0065
Mailing Address - Fax:
Practice Address - Street 1:4350 211TH ST STE 210A
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3082
Practice Address - Country:US
Practice Address - Phone:312-818-1192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical