Provider Demographics
NPI:1417128679
Name:WILSON, ELISA JULIA THERESA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:JULIA THERESA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 DEPOT ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2629
Mailing Address - Country:US
Mailing Address - Phone:203-347-5271
Mailing Address - Fax:
Practice Address - Street 1:51 DEPOT ST
Practice Address - Street 2:SUITE 209
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2629
Practice Address - Country:US
Practice Address - Phone:203-347-5271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical