Provider Demographics
NPI:1649367418
Name:WILSON, JOSEPH CARROLL (MSW,LCSW)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:CARROLL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2430
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638
Mailing Address - Country:US
Mailing Address - Phone:208-634-2899
Mailing Address - Fax:208-634-2564
Practice Address - Street 1:200 FOREST ST.
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638
Practice Address - Country:US
Practice Address - Phone:208-634-2899
Practice Address - Fax:208-634-2564
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM.S.W.,L.C.S.W 900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDL9024OtherBLUE CROSS
IDREGENCE/BLUE SHIELDOther000010017445