Healthcare Provider Details

I. General information

NPI: 1174284020
Provider Name (Legal Business Name): DARA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 MASS AVE
ARLINGTON MA
02476-5002
US

IV. Provider business mailing address

70 SAINT JOSEPH AVE
FITCHBURG MA
01420-4023
US

V. Phone/Fax

Practice location:
  • Phone: 617-444-9487
  • Fax:
Mailing address:
  • Phone: 617-444-9487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23927
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: