Provider Demographics
NPI:1386094290
Name:WILKINSON, CHARLES PRUITT
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PRUITT
Last Name:WILKINSON
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 1:5115 F ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68117-2807
Mailing Address - Country:US
Mailing Address - Phone:308-539-3282
Mailing Address - Fax:
Practice Address - Street 1:2300 S 13TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502
Practice Address - Country:US
Practice Address - Phone:308-539-3282
Practice Address - Fax:402-474-4668
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEH13346275101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health