Provider Demographics
NPI:1114658176
Name:WILSON, COURTNEY JERMAINE (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:JERMAINE
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9346 NW 49TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5261
Mailing Address - Country:US
Mailing Address - Phone:646-667-3727
Mailing Address - Fax:
Practice Address - Street 1:9346 NW 49TH PL
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-5261
Practice Address - Country:US
Practice Address - Phone:646-667-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL197931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical