Healthcare Provider Details

I. General information

NPI: 1821205444
Provider Name (Legal Business Name): THERESA C WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 DUDLEY AVE
CHERRY HILL NJ
08002-4426
US

IV. Provider business mailing address

900 DUDLEY AVE
CHERRY HILL NJ
08002-4426
US

V. Phone/Fax

Practice location:
  • Phone: 856-541-1700
  • Fax: 856-488-5530
Mailing address:
  • Phone: 856-541-1700
  • Fax: 856-488-5530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC00000700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: