Provider Demographics
NPI:1841737673
Name:WILSON, WAYNE R (LCSW)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:DOC
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:736 BRIDGE ST UNIT 11
Mailing Address - Street 2:
Mailing Address - City:VERNONIA
Mailing Address - State:OR
Mailing Address - Zip Code:97064-1285
Mailing Address - Country:US
Mailing Address - Phone:707-797-0064
Mailing Address - Fax:707-797-0064
Practice Address - Street 1:70 EAST TERRACE DR
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91101
Practice Address - Country:US
Practice Address - Phone:707-797-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW754821041C0700X
CALCSW914411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical