Provider Demographics
NPI:1407669039
Name:WILSON, DUSTY RANDALL
Entity type:Individual
Prefix:
First Name:DUSTY
Middle Name:RANDALL
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 1:3940 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-2432
Mailing Address - Country:US
Mailing Address - Phone:402-440-3185
Mailing Address - Fax:
Practice Address - Street 1:3940 N 9TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-2432
Practice Address - Country:US
Practice Address - Phone:402-440-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker