Healthcare Provider Details

I. General information

NPI: 1144141938
Provider Name (Legal Business Name): CHRISTOPHER DALE WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 OLD WHITLEY RD
LONDON KY
40744-9113
US

IV. Provider business mailing address

3800 OLD WHITLEY RD
LONDON KY
40744-9113
US

V. Phone/Fax

Practice location:
  • Phone: 606-224-9538
  • Fax:
Mailing address:
  • Phone: 606-224-9538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number310380
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: