Provider Demographics
NPI:1013387273
Name:WILSON, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BELMONT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2561
Mailing Address - Country:US
Mailing Address - Phone:646-573-4153
Mailing Address - Fax:
Practice Address - Street 1:665 BEACON ST STE 300
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3202
Practice Address - Country:US
Practice Address - Phone:617-485-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA11276103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program