MEDICARE: MS. WENDY ANN WILSON C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R018164	NY

General Provider Information

NPI Number	:	1083783070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WENDY ANN WILSON C.S.W.

Provider Business Mailing Address
First Line	:	9 BAY DR
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-7303
Country	:	US
Telephone Number	:	516-798-4999
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 BAY DR
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-7303
Country	:	US
Telephone Number	:	516-798-4999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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