Provider Demographics
NPI:1699864405
Name:WILSON, ANTHONY WAYNE (EDD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2322 PANSY ST SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3803
Mailing Address - Country:US
Mailing Address - Phone:256-533-7485
Mailing Address - Fax:
Practice Address - Street 1:2322 PANSY ST SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3803
Practice Address - Country:US
Practice Address - Phone:256-533-7485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical