Provider Demographics
NPI:1730896556
Name:WILSON, DEMETRIUS
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 621
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-0621
Mailing Address - Country:US
Mailing Address - Phone:336-884-2162
Mailing Address - Fax:
Practice Address - Street 1:5060 N 19TH AVE STE 300-21
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3210
Practice Address - Country:US
Practice Address - Phone:480-853-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician