Healthcare Provider Details

I. General information

NPI: 1548313281
Provider Name (Legal Business Name): BRUCE LESLIE WILSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 POPLAR RD STE E
BRIARCLIFF MANOR NY
10510-1206
US

IV. Provider business mailing address

PO BOX 121
BRIARCLIFF MANOR NY
10510-0121
US

V. Phone/Fax

Practice location:
  • Phone: 914-666-0060
  • Fax: 914-666-9662
Mailing address:
  • Phone: 914-666-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number009606
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0096961
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: