Provider Demographics
NPI:1164019881
Name:WILSON, MARISA (MS LBS)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:RIEGELSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18077-8013
Mailing Address - Country:US
Mailing Address - Phone:484-769-6091
Mailing Address - Fax:
Practice Address - Street 1:1106 EASTON RD
Practice Address - Street 2:
Practice Address - City:RIEGELSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18077-8013
Practice Address - Country:US
Practice Address - Phone:484-769-6091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH004434OtherCOMMONWEALTH OF PA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL