Healthcare Provider Details

I. General information

NPI: 1891602256
Provider Name (Legal Business Name): DEREK LEE WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 CHESAPEAKE DR
GREENSBORO NC
27410-3527
US

IV. Provider business mailing address

1710 CHESAPEAKE DR
GREENSBORO NC
27410-3527
US

V. Phone/Fax

Practice location:
  • Phone: 336-316-9208
  • Fax:
Mailing address:
  • Phone: 336-316-9208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: