MEDICARE: DYLAN MARSHALL WILSON MSW, LMSW

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	104100000X	Social Worker	117027-01	NY

General Provider Information

NPI Number	:	1336856129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYLAN MARSHALL WILSON MSW, LMSW

Provider Business Mailing Address
First Line	:	888 E 6TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10009-7128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 JEFFERSON ST APT 1B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11206-5838
Country	:	US
Telephone Number	:	405-255-1913
Fax Number	:

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

Provider Enumeration Date	:	11/01/2022
Last Update Date	:	11/01/2022

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