Provider Demographics
NPI:1295006195
Name:WILSON, CHARLES ISAIAH IV
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ISAIAH
Last Name:WILSON
Suffix:IV
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:PO BOX 16906
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6906
Mailing Address - Country:US
Mailing Address - Phone:602-279-1427
Mailing Address - Fax:602-279-1431
Practice Address - Street 1:4449 N 12TH ST
Practice Address - Street 2:SUITE A1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4520
Practice Address - Country:US
Practice Address - Phone:602-279-1427
Practice Address - Fax:602-279-1431
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3664065104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker