Healthcare Provider Details

I. General information

NPI: 1467703033
Provider Name (Legal Business Name): MARVIN D'ANDRE WILSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S BURROWES ST SUITE 607
STATE COLLEGE PA
16801-3863
US

IV. Provider business mailing address

119 S BURROWES ST SUITE 607
STATE COLLEGE PA
16801-3863
US

V. Phone/Fax

Practice location:
  • Phone: 814-238-0921
  • Fax: 814-238-1875
Mailing address:
  • Phone: 814-238-0921
  • Fax: 814-238-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSO17102
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: