Provider Demographics
NPI:1063622421
Name:WILSON, JOSEPH EDWARD (PHD, LCSW-BACS, LAC)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:EDWARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD, LCSW-BACS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 OAKLAWN AVE.
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506
Mailing Address - Country:US
Mailing Address - Phone:225-803-2963
Mailing Address - Fax:
Practice Address - Street 1:623 OAKLAWN AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3305
Practice Address - Country:US
Practice Address - Phone:225-803-2963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC-778101YA0400X
LALCSW-2289B1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)