Healthcare Provider Details

I. General information

NPI: 1073290821
Provider Name (Legal Business Name): KARL STEPHEN WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 WAKEFIELD CIR # 98
EAST HARTFORD CT
06118-1630
US

IV. Provider business mailing address

98 WAKEFIELD CIR # 98
EAST HARTFORD CT
06118-1630
US

V. Phone/Fax

Practice location:
  • Phone: 860-655-2429
  • Fax:
Mailing address:
  • Phone: 860-655-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7304
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: