Basic Information
| Provider Information | |||||||||
| NPI: | 1174159610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RICKY | ||||||||
| MiddleName: | DALE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6570 SOSNA DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450142222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139424673 | ||||||||
| FaxNumber: | 5137371107 | ||||||||
| Practice Location | |||||||||
| Address1: | 6570 SOSNA DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450142222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139424673 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2020 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.174383 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106S00000X | N |
No ID Information.