Healthcare Provider Details

I. General information

NPI: 1215623731
Provider Name (Legal Business Name): ALEXANDRA EVELYN WILSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S ACADEMY AVE
EAGLE ID
83616-6541
US

IV. Provider business mailing address

136 S ACADEMY AVE
EAGLE ID
83616-6541
US

V. Phone/Fax

Practice location:
  • Phone: 208-254-1112
  • Fax:
Mailing address:
  • Phone: 208-254-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number39725
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: