Provider Demographics
NPI:1295176733
Name:WILSON, THERESA ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
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:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-4000
Mailing Address - Country:US
Mailing Address - Phone:928-737-6188
Mailing Address - Fax:928-737-6098
Practice Address - Street 1:MILEPOST 388 HIGHWAY 264
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042-4000
Practice Address - Country:US
Practice Address - Phone:928-737-6188
Practice Address - Fax:928-737-6098
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY06980811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical