Provider Demographics
NPI:1902963739
Name:WILSON, GEOFFREY DAVID (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 BLACKMOOR PARK LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8490
Mailing Address - Country:US
Mailing Address - Phone:859-229-5722
Mailing Address - Fax:859-294-0802
Practice Address - Street 1:501 DARBY CREEK RD
Practice Address - Street 2:SUITE 14
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1604
Practice Address - Country:US
Practice Address - Phone:859-229-5722
Practice Address - Fax:859-294-0802
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY649101YA0400X
KY13321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical