Provider Demographics
NPI:1548481518
Name:WILSON, SAM C (LCSW)
Entity type:Individual
Prefix:MR
First Name:SAM
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:SAM
Other - Middle Name:CHADWICK
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:512-440-4059
Practice Address - Street 1:1631 E 2ND ST
Practice Address - Street 2:B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4490
Practice Address - Country:US
Practice Address - Phone:512-804-3366
Practice Address - Fax:512-804-3672
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX039281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical