Provider Demographics
NPI:1528211232
Name:WILSON, LARRY JAMES (LCSW, LMSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1572 ZEPHYR AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-3560
Mailing Address - Country:US
Mailing Address - Phone:619-588-8811
Mailing Address - Fax:
Practice Address - Street 1:1572 ZEPHYR AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-3560
Practice Address - Country:US
Practice Address - Phone:619-588-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-25
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL9105941041C0700X
CALCSW289011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical