Provider Demographics
NPI:1972683894
Name:WILSON, FRAZIER CLETHON JR (LISW, LADAC)
Entity Type:Individual
Prefix:
First Name:FRAZIER
Middle Name:CLETHON
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:LISW, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 MILES RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3224
Mailing Address - Country:US
Mailing Address - Phone:505-974-7602
Mailing Address - Fax:505-842-1503
Practice Address - Street 1:2418 MILES RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3224
Practice Address - Country:US
Practice Address - Phone:505-974-7602
Practice Address - Fax:505-842-1503
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-067091041C0700X
NM0093531101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI-06709OtherLICENSE
NM0093531OtherLICENSE