Healthcare Provider Details

I. General information

NPI: 1669351789
Provider Name (Legal Business Name): WILSON STROCKY PERRIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 KINGSBRIDGE AVE
BRONX NY
10463-5514
US

IV. Provider business mailing address

17222 133RD AVE APT 12A
JAMAICA NY
11434-3911
US

V. Phone/Fax

Practice location:
  • Phone: 646-204-2295
  • Fax:
Mailing address:
  • Phone: 347-994-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: