Provider Demographics
NPI:1669053443
Name:WILSON, SETH HOWARD
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:HOWARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W PASADENA AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2342
Mailing Address - Country:US
Mailing Address - Phone:971-219-8007
Mailing Address - Fax:
Practice Address - Street 1:2055 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5157
Practice Address - Country:US
Practice Address - Phone:971-219-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC61127538104100000X
AZLMSW-18808104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker