Healthcare Provider Details

I. General information

NPI: 1528623022
Provider Name (Legal Business Name): CARLA SACHIKO WILSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 BOONE AVE N
NEW HOPE MN
55428-3636
US

IV. Provider business mailing address

1824 19TH AVE NE
MINNEAPOLIS MN
55418-4726
US

V. Phone/Fax

Practice location:
  • Phone: 763-504-8821
  • Fax:
Mailing address:
  • Phone: 612-385-1082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24832
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: