Healthcare Provider Details

I. General information

NPI: 1184322273
Provider Name (Legal Business Name): LIETEA WILKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 PEARSALL AVE APT 2
JERSEY CITY NJ
07305-1814
US

IV. Provider business mailing address

400 RARITAN AVE
HIGHLAND PARK NJ
08904-2740
US

V. Phone/Fax

Practice location:
  • Phone: 973-385-9801
  • Fax:
Mailing address:
  • Phone: 732-845-6602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number15BC00294500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: