Provider Demographics
NPI:1922535285
Name:WILSON, NATASHA SANDRAYA (LCSW)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:SANDRAYA
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 1:183 MASSACHUSETTS AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2561
Mailing Address - Country:US
Mailing Address - Phone:207-210-7631
Mailing Address - Fax:
Practice Address - Street 1:183 MASSACHUSETTS AVE APT 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2561
Practice Address - Country:US
Practice Address - Phone:207-210-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC166451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical