Provider Demographics
NPI:1073290821
Name:WILSON, KARL STEPHEN
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:STEPHEN
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 1:98 WAKEFIELD CIR # 98
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-1630
Mailing Address - Country:US
Mailing Address - Phone:860-655-2429
Mailing Address - Fax:
Practice Address - Street 1:98 WAKEFIELD CIR # 98
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1630
Practice Address - Country:US
Practice Address - Phone:860-655-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT73041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical