Healthcare Provider Details

I. General information

NPI: 1891825048
Provider Name (Legal Business Name): NESSA MARIE WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54771 MCKENZIE HWY
BLUE RIVER OR
97413-9790
US

IV. Provider business mailing address

367 W JEFFERSON AVE
SISTERS OR
97759-1439
US

V. Phone/Fax

Practice location:
  • Phone: 541-822-3341
  • Fax:
Mailing address:
  • Phone: 541-280-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6027
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: