Provider Demographics
NPI:1366708216
Name:WILSON, MICHAEL CHAD (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHAD
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10421 W BROWNSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5612
Mailing Address - Country:US
Mailing Address - Phone:208-724-0913
Mailing Address - Fax:
Practice Address - Street 1:10421 W BROWNSTONE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5612
Practice Address - Country:US
Practice Address - Phone:208-724-0913
Practice Address - Fax:208-561-8373
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-319061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical