=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356059844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN WILSON LCSW, LCAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2022
-----------------------------------------------------
Last Update Date | 05/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9623 WINDERMERE BLVD
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46037-9180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-416-4646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 DIAMOND LN
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-8320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-918-3923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34010348A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 87001672A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------