Provider Demographics
NPI:1285173054
Name:WILSON, SANDY (LCSW)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:PA
Mailing Address - Zip Code:15475-0308
Mailing Address - Country:US
Mailing Address - Phone:724-963-6137
Mailing Address - Fax:
Practice Address - Street 1:627 PITTSBURGH RD STE 2
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2200
Practice Address - Country:US
Practice Address - Phone:734-439-4990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0198891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical