Healthcare Provider Details

I. General information

NPI: 1740835651
Provider Name (Legal Business Name): ZACHARY A WILSON LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MOUNT ROYAL AVE STE 4-360
MARLBOROUGH MA
01752-1961
US

IV. Provider business mailing address

4 MOUNT ROYAL AVE STE 4-360
MARLBOROUGH MA
01752-1961
US

V. Phone/Fax

Practice location:
  • Phone: 978-222-3121
  • Fax:
Mailing address:
  • Phone: 603-498-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW111525
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: