Provider Demographics
NPI:1861173627
Name:WILSON, DEREK PAYSON (MED)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:PAYSON
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1519
Mailing Address - Country:US
Mailing Address - Phone:860-378-8090
Mailing Address - Fax:
Practice Address - Street 1:791 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-1519
Practice Address - Country:US
Practice Address - Phone:860-378-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
CT8592101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health