Provider Demographics
NPI:1083783070
Name:WILSON, WENDY ANN (CSW)
Entity type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BAY DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7303
Mailing Address - Country:US
Mailing Address - Phone:516-798-4999
Mailing Address - Fax:
Practice Address - Street 1:9 BAY DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-7303
Practice Address - Country:US
Practice Address - Phone:516-798-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0181641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN20431Medicare ID - Type Unspecified