1902963739 NPI number — GEOFFREY DAVID WILSON LCSW, CADC

Table of content: GEOFFREY DAVID WILSON LCSW, CADC (NPI 1902963739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902963739 NPI number — GEOFFREY DAVID WILSON LCSW, CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
GEOFFREY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, CADC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902963739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2241 BLACKMOOR PARK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40509-8490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-229-5722
Provider Business Mailing Address Fax Number:
859-294-0802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 DARBY CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 14
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40509-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-229-5722
Provider Business Practice Location Address Fax Number:
859-294-0802
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  649 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: 1332 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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