1346664661 NPI number — SANDRA KATHRYN WILSON LCSW, ASOTP

Table of content: SANDRA KATHRYN WILSON LCSW, ASOTP (NPI 1346664661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346664661 NPI number — SANDRA KATHRYN WILSON LCSW, ASOTP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
SANDRA
Provider Middle Name:
KATHRYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, ASOTP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRUCE
Provider Other First Name:
SANDRA
Provider Other Middle Name:
KATHRYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346664661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5825 PHELAN BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77706-6249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-860-0001
Provider Business Mailing Address Fax Number:
409-860-0010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5825 PHELAN BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77706-6249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-860-0001
Provider Business Practice Location Address Fax Number:
409-860-0010
Provider Enumeration Date:
02/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  23427 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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