Provider Demographics
NPI:1104307412
Name:WILSON, HARVEY TAYLOR (LICSW)
Entity type:Individual
Prefix:
First Name:HARVEY
Middle Name:TAYLOR
Last Name:WILSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BAYBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657-1214
Mailing Address - Country:US
Mailing Address - Phone:508-487-2735
Mailing Address - Fax:
Practice Address - Street 1:21 BAYBERRY AVE
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1214
Practice Address - Country:US
Practice Address - Phone:508-487-2735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1016242-SW-LICSW101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health