Provider Demographics
NPI:1528623022
Name:WILSON, CARLA SACHIKO (LICSW)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:SACHIKO
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 19TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4726
Mailing Address - Country:US
Mailing Address - Phone:612-385-1082
Mailing Address - Fax:
Practice Address - Street 1:5555 BOONE AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3636
Practice Address - Country:US
Practice Address - Phone:763-504-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN248321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical