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General NPI Number Information
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NPI Number | 1972683894
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Entity Type | Individual
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Provider Name | FRAZIER CLETHON WILSON JR. LISW, LADAC
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Gender | Male
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 12/07/2009
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Provider Practice Location Address
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Address Line | 2418 MILES RD SE
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-3224
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Country | US
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Telephone | 505-974-7602
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Fax | 505-842-1503
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Provider Business Mailing Address
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Address Line | 2418 MILES RD SE
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-3224
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Country | US
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Telephone | 505-974-7602
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Fax | 505-842-1503
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-06709
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0093531
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License Number State | NM
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