Basic Information
| Provider Information | |||||||||
| NPI: | 1063883544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BLAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, MED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 CANAL ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701196084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044822735 | ||||||||
| FaxNumber: | 5044822737 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 CANAL ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701196084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044822735 | ||||||||
| FaxNumber: | 5044822737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 13231 | LA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | CW018726 | PA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.