Healthcare Provider Details

I. General information

NPI: 1982901435
Provider Name (Legal Business Name): DALE WILSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6126 W STATE ST STE 101
BOISE ID
83703-2741
US

IV. Provider business mailing address

7983 W WHITTAKER ST
BOISE ID
83714-2055
US

V. Phone/Fax

Practice location:
  • Phone: 208-713-9627
  • Fax:
Mailing address:
  • Phone: 208-713-9627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCSW - 33650
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCSW - 33650
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLCSW - 33650
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW - 33650
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: