Provider Demographics
NPI:1700970431
Name:WILSON, JANICE SUSAN (LISW)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:SUSAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MRS
Other - First Name:J.
Other - Middle Name:SUSAN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 2870
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-2870
Mailing Address - Country:US
Mailing Address - Phone:505-624-2661
Mailing Address - Fax:505-625-0643
Practice Address - Street 1:300 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4600
Practice Address - Country:US
Practice Address - Phone:505-624-2661
Practice Address - Fax:505-625-0643
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-05660104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17104815Medicaid