Healthcare Provider Details

I. General information

NPI: 1679907984
Provider Name (Legal Business Name): BRYAN WILSON ED.D., NCSP, BC-TMH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2013
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PUTNAM ST STE 410
MARIETTA OH
45750-3009
US

IV. Provider business mailing address

1648 GREATHOUSE RD
WILLIAMSTOWN WV
26187-8400
US

V. Phone/Fax

Practice location:
  • Phone: 740-401-9766
  • Fax:
Mailing address:
  • Phone: 304-550-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberSP.00685
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSP.00685
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberN3R136200287
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: