Provider Demographics
NPI:1700105053
Name:WILSON, HAZEL A (LISW)
Entity Type:Individual
Prefix:MS
First Name:HAZEL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:DR
Other - First Name:HAZEL
Other - Middle Name:ARLEAN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMIN
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5674
Mailing Address - Country:US
Mailing Address - Phone:912-435-6367
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5674
Practice Address - Country:US
Practice Address - Phone:912-435-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0068101041C0700X
SC100961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC3343Medicare PIN