Healthcare Provider Details

I. General information

NPI: 1629043609
Provider Name (Legal Business Name): KEITH A WILSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEITH FOSTER-WILSON

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

PO BOX 40406
NASHVILLE TN
37204-0406
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8601
  • Fax: 270-798-8239
Mailing address:
  • Phone: 615-463-6608
  • Fax: 615-463-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004702
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: