Provider Demographics
NPI:1063883544
Name:WILSON, BLAINE (LCSW, MED)
Entity type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 CANAL ST STE 220
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6084
Mailing Address - Country:US
Mailing Address - Phone:504-482-2735
Mailing Address - Fax:504-482-2737
Practice Address - Street 1:3801 CANAL ST STE 220
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6084
Practice Address - Country:US
Practice Address - Phone:504-482-2735
Practice Address - Fax:504-482-2737
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13231104100000X
PACW0187261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker