Provider Demographics
NPI:1346664661
Name:WILSON, SANDRA KATHRYN (LCSW, ASOTP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KATHRYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW, ASOTP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:KATHRYN
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5825 PHELAN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6249
Mailing Address - Country:US
Mailing Address - Phone:409-860-0001
Mailing Address - Fax:409-860-0010
Practice Address - Street 1:5825 PHELAN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6249
Practice Address - Country:US
Practice Address - Phone:409-860-0001
Practice Address - Fax:409-860-0010
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX234271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080462703Medicare Oscar/Certification