| Doctor Name: | MS. THERESA ANN WILSON |
| NPI Number: | 1295176733 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW |
| License Number: | 0698081 |
| Business Practice Address: | Milepost 388 Highway 264 Polacca, AZ - 860424000 |
| Business Phone Number: | 9287376188 |
| Business Fax Number: | 9287376098 |
| Mailing Address: | Po Box 4000, POLACCA |
| State: | AZ |
| Postal Code: | 860424000 |
| Phone Number: | 9287376188 |
| Fax Number: | 9287376098 |
| NPI Enumeration Date: | 07/12/2013 |
| NPI Last Update Date: | 07/12/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 0698081 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |