Provider Demographics
NPI:1952640831
Name:WILSON, WANDA L (LCSW)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:L
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6615 S ACACIA ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6683
Mailing Address - Country:US
Mailing Address - Phone:208-918-4894
Mailing Address - Fax:
Practice Address - Street 1:6615 S ACACIA ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6683
Practice Address - Country:US
Practice Address - Phone:208-918-4894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-31942101YM0800X
IDLCSW-45394101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health