Provider Demographics
NPI:1093084683
Name:WILSON, ROBERT W (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E SOUTHERN AVE
Mailing Address - Street 2:STE. 735
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5691
Mailing Address - Country:US
Mailing Address - Phone:480-804-0326
Mailing Address - Fax:480-804-0083
Practice Address - Street 1:2120 S MCCLINTOCK DR
Practice Address - Street 2:SUITE 105
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2692
Practice Address - Country:US
Practice Address - Phone:480-804-0326
Practice Address - Fax:480-804-0083
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-102941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ668301Medicaid
AZZ173580Medicare PIN