Healthcare Provider Details

I. General information

NPI: 1619430444
Provider Name (Legal Business Name): DAVA R WILSON CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DAVA WHITAKER

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 FAIRWAY ST STE 320
BOWLING GREEN KY
42103-2452
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9058
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-6307
  • Fax: 270-904-6314
Mailing address:
  • Phone: 419-695-8010
  • Fax: 419-695-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number253861
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: