Provider Demographics
NPI:1811065097
Name:WILSON, RUTH A (LICSW)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01740-1300
Mailing Address - Country:US
Mailing Address - Phone:978-779-6505
Mailing Address - Fax:978-779-0211
Practice Address - Street 1:563 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:MA
Practice Address - Zip Code:01740-1300
Practice Address - Country:US
Practice Address - Phone:978-779-6505
Practice Address - Fax:978-779-0211
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1017004104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04883Medicare ID - Type Unspecified