Healthcare Provider Details

I. General information

NPI: 1326201963
Provider Name (Legal Business Name): JAMES KEVIN WILSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 BROADWAY 713
NEW YORK NY
10006-2503
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 212-430-3891
  • Fax: 212-430-3892
Mailing address:
  • Phone: 212-564-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR053331-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: