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NPI Code Detail

MEDICARE: CHARRISSE LEIANA WILSON LCSW

MEDICARE: CHARRISSE LEIANA WILSON LCSW
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
11041C0700XClinical Social Worker

General Provider Information

NPI Number : 1639853013
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARRISSE LEIANA WILSON LCSW
Provider Business Mailing Address
First Line : 27 RANDOLPH RD
Second Line :
City : HOWELL
State : NJ
Zip : 07731-8611
Country : US
Telephone Number : 718-506-1115
Fax Number :
Provider Business Practice Location Address
First Line : 211 E 1ST ST
Second Line :
City : BLOOMSBURG
State : PA
Zip : 17815-1405
Country : US
Telephone Number : 718-506-1115
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2023
Last Update Date : 06/14/2023

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