Provider Demographics
NPI:1730335035
Name:WILSON, SHIRLEY MARIE (CASAC)
Entity type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25307 148TH DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2815
Mailing Address - Country:US
Mailing Address - Phone:718-413-2372
Mailing Address - Fax:
Practice Address - Street 1:500 8TH AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-6504
Practice Address - Country:US
Practice Address - Phone:212-904-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20123101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)