Basic Information
| Provider Information | |||||||||
| NPI: | 1447888045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 RIVER DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278044414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284932515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 CHARLOTTE HWY STE E | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288038681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283335708 | ||||||||
| FaxNumber: | 8284841025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2020 | ||||||||
| LastUpdateDate: | 04/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P014128 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.