Healthcare Provider Details

I. General information

NPI: 1235464686
Provider Name (Legal Business Name): NATASHA MARIE WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TWINING ST
MAXWELL AFB AL
36112-6027
US

IV. Provider business mailing address

108 CANTERA WAY
PIKE ROAD AL
36064-2975
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-5055
  • Fax:
Mailing address:
  • Phone: 302-399-8835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6635C
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-4985
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17322
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0001790
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: