Healthcare Provider Details

I. General information

NPI: 1992032593
Provider Name (Legal Business Name): MRS. MICHELLE WILSUSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE PRIZEMAN LCSW

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2277 GRAND AVE
BALDWIN NY
11510-3148
US

IV. Provider business mailing address

2277 GRAND AVE
BALDWIN NY
11510-3148
US

V. Phone/Fax

Practice location:
  • Phone: 516-377-5400
  • Fax:
Mailing address:
  • Phone: 516-377-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078022
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number076326
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: