Provider Demographics
NPI:1093141061
Name:WILSON, MAXINE E
Entity Type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SCUPPO RD
Mailing Address - Street 2:UNIT 1001
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-5303
Mailing Address - Country:US
Mailing Address - Phone:203-826-7713
Mailing Address - Fax:203-826-7713
Practice Address - Street 1:15 SCUPPO RD
Practice Address - Street 2:UNIT1001
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-5303
Practice Address - Country:US
Practice Address - Phone:203-826-7713
Practice Address - Fax:203-826-7713
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-22
Last Update Date:2013-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY657894174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY657894OtherSPECIAL EDUCATION