Provider Demographics
NPI:1760664221
Name:WILSON, CAROLYN TARVER (MED SOCIAL WORKER)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:TARVER
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 WREN AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-3835
Mailing Address - Country:US
Mailing Address - Phone:502-848-4225
Mailing Address - Fax:502-848-8822
Practice Address - Street 1:621 WREN AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-3835
Practice Address - Country:US
Practice Address - Phone:502-848-4225
Practice Address - Fax:502-848-8822
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3253104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker