Provider Demographics
NPI:1114257805
Name:WILSON, PENELOPE (LCSW, EDM)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW, EDM
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PWILSON LCSW
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-0616
Mailing Address - Country:US
Mailing Address - Phone:203-300-6655
Mailing Address - Fax:
Practice Address - Street 1:30 OLD KINGS HWY S
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4551
Practice Address - Country:US
Practice Address - Phone:203-300-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075598-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical