Provider Demographics
NPI:1982901435
Name:WILSON, DALE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7983 W WHITTAKER ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-2055
Mailing Address - Country:US
Mailing Address - Phone:208-713-9627
Mailing Address - Fax:
Practice Address - Street 1:6126 W STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2741
Practice Address - Country:US
Practice Address - Phone:208-713-9627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW - 33650101Y00000X, 101YA0400X, 101YP1600X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral