Provider Demographics
NPI:1114600962
Name:WILSON, ALEXANDER BASIL EDWARD (LMSW)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:BASIL EDWARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 LIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1648
Mailing Address - Country:US
Mailing Address - Phone:631-891-9613
Mailing Address - Fax:
Practice Address - Street 1:131 NY-25A STE 4
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778
Practice Address - Country:US
Practice Address - Phone:516-297-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116438104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker