Healthcare Provider Details

I. General information

NPI: 1700909538
Provider Name (Legal Business Name): MARY JO WILSON PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY JO CASTRO

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 57TH ST SUITE 402
NEW YORK NY
10019-3158
US

IV. Provider business mailing address

484 W 43RD ST 44-M
NEW YORK NY
10036-6319
US

V. Phone/Fax

Practice location:
  • Phone: 212-757-6607
  • Fax: 212-757-2932
Mailing address:
  • Phone: 212-564-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number010284
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: