Provider Demographics
NPI:1487192688
Name:WILSON, CHARLES DALTON JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DALTON
Last Name:WILSON
Suffix:JR
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 1:12607 PENNING BLF
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-4351
Mailing Address - Country:US
Mailing Address - Phone:832-690-8432
Mailing Address - Fax:
Practice Address - Street 1:12607 PENNING BLF
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-4351
Practice Address - Country:US
Practice Address - Phone:832-690-8432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX673291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical