Healthcare Provider Details

I. General information

NPI: 1871479170
Provider Name (Legal Business Name): CHERYL WILSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 690139
EAST ELMHURST NY
11369-0139
US

IV. Provider business mailing address

PO BOX 690139
EAST ELMHURST NY
11369-0139
US

V. Phone/Fax

Practice location:
  • Phone: 646-643-8648
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: