Provider Demographics
NPI:1255098919
Name:WILSON, ROBERT (MT CLT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MT CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 MACOPIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07480-1508
Mailing Address - Country:US
Mailing Address - Phone:201-615-7317
Mailing Address - Fax:
Practice Address - Street 1:66 NEWARK POMPTON TPKE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457-1420
Practice Address - Country:US
Practice Address - Phone:973-858-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18KT01301400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty