Provider Demographics
NPI:1215623731
Name:WILSON, ALEXANDRA EVELYN (LMSW)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:EVELYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 S ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6541
Mailing Address - Country:US
Mailing Address - Phone:208-254-1112
Mailing Address - Fax:
Practice Address - Street 1:136 S ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6541
Practice Address - Country:US
Practice Address - Phone:208-254-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39725104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker