Provider Demographics
NPI:1720899040
Name:WILSON, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
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 1:221 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-1264
Mailing Address - Country:US
Mailing Address - Phone:740-342-1991
Mailing Address - Fax:
Practice Address - Street 1:511 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1206
Practice Address - Country:US
Practice Address - Phone:174-034-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.001571175T00000X
OHCDCA.191182101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist