Provider Demographics
NPI:1447888045
Name:WILSON, BRYAN PAUL (LCSWA)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-4414
Mailing Address - Country:US
Mailing Address - Phone:828-493-2515
Mailing Address - Fax:
Practice Address - Street 1:204 CHARLOTTE HWY STE E
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-8681
Practice Address - Country:US
Practice Address - Phone:828-333-5708
Practice Address - Fax:828-484-1025
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0141281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical