Provider Demographics
NPI:1962524207
Name:WILSON, JOHN F III
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:WILSON
Suffix:III
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:PO BOX 912
Mailing Address - Street 2:
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-0912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1135 SEVEN LAKES DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376
Practice Address - Country:US
Practice Address - Phone:910-638-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2300103T00000X, 103TA0400X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TH0100X, 103TM1800X, 103TP2701X, 103TR0400X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3403400Medicaid
NC13973OtherBCBS
NC562033116OtherTRICARETAX ID