Healthcare Provider Details

I. General information

NPI: 1790218915
Provider Name (Legal Business Name): HEATHER WILSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

1416 MORING ST
RALEIGH NC
27603-2350
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8898
  • Fax:
Mailing address:
  • Phone: 443-812-0306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC012252
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number22040
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: