Basic Information
| Provider Information | |||||||||
| NPI: | 1619430444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DAVA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CSW | ||||||||
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| OtherLastName: | WHITAKER | ||||||||
| OtherFirstName: | DAVA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10100 ELIDA RD | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196958010 | ||||||||
| FaxNumber: | 4196950004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1143 FAIRWAY ST STE 320 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421032452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709046307 | ||||||||
| FaxNumber: | 2709046314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2019 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 253861 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.