Healthcare Provider Details

I. General information

NPI: 1427633411
Provider Name (Legal Business Name): DOUGLAS WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E MARKET ST FL 3
LIMA OH
45801-4535
US

IV. Provider business mailing address

311 E MARKET ST FL 3
LIMA OH
45801-4535
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-4474
  • Fax: 419-222-7044
Mailing address:
  • Phone: 419-222-4474
  • Fax: 419-222-7044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.180516
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number180516
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0315095
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: