Basic Information
| Provider Information | |||||||||
| NPI: | 1275124901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DARIUS | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722094728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012650302 | ||||||||
| FaxNumber: | 5012650302 | ||||||||
| Practice Location | |||||||||
| Address1: | 6210 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722094728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012650302 | ||||||||
| FaxNumber: | 5012650300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2021 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 9650-M | AR | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.