Healthcare Provider Details

I. General information

NPI: 1497610059
Provider Name (Legal Business Name): WIL TO WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WALNUT AVE
CLARK NJ
07066-1253
US

IV. Provider business mailing address

100 WALNUT AVE
CLARK NJ
07066-1253
US

V. Phone/Fax

Practice location:
  • Phone: 917-722-1266
  • Fax:
Mailing address:
  • Phone: 917-722-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: WILANDA NICOLAS
Title or Position: MANAGING MEMBER
Credential: LPC
Phone: 917-722-1266