Healthcare Provider Details

I. General information

NPI: 1942315494
Provider Name (Legal Business Name): ANTHONY CHRISTOPHER WILSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD BLDG 2040
MALMSTROM AFB MT
59402-6701
US

IV. Provider business mailing address

655 7TH ST BLDG 700700-A 78 MDG/SGOW
ROBINS AFB GA
31098-2227
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-3219
  • Fax: 406-731-3231
Mailing address:
  • Phone: 478-327-8403
  • Fax: 478-327-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50078660
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: