Healthcare Provider Details

I. General information

NPI: 1891192878
Provider Name (Legal Business Name): CANDACE DOROTHY WILSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDACE DOROTHY WILSON LPC

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 PARK AVE
PLAINFIELD NJ
07060-3253
US

IV. Provider business mailing address

26 DRAPER TER
MONTCLAIR NJ
07042-4440
US

V. Phone/Fax

Practice location:
  • Phone: 973-755-3392
  • Fax: 973-755-4758
Mailing address:
  • Phone: 973-583-9604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00507700
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: