Provider Demographics
NPI:1487907358
Name:WILSON, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 - 4TH ST. N.
Mailing Address - Street 2:#327
Mailing Address - City:ST. PETE
Mailing Address - State:FL
Mailing Address - Zip Code:33702
Mailing Address - Country:US
Mailing Address - Phone:727-374-0108
Mailing Address - Fax:727-374-0108
Practice Address - Street 1:7901 - 4TH ST. N.
Practice Address - Street 2:#327
Practice Address - City:ST. PETE
Practice Address - State:FL
Practice Address - Zip Code:33702
Practice Address - Country:US
Practice Address - Phone:727-374-0108
Practice Address - Fax:727-374-0108
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW004971101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor