Provider Demographics
NPI:1083959597
Name:WILSON PSYCHOLOGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:WILSON PSYCHOLOGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:973-234-2345
Mailing Address - Street 1:416 POMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1813
Mailing Address - Country:US
Mailing Address - Phone:973-239-2345
Mailing Address - Fax:973-559-9162
Practice Address - Street 1:416 POMPTON AVE
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1813
Practice Address - Country:US
Practice Address - Phone:973-239-2345
Practice Address - Fax:973-559-9162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100492700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty