Provider Demographics
NPI:1174674659
Name:WILSON, DANIEL EUGENE (SLP)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:EUGENE
Last Name:WILSON
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 LIBERTY AVE
Mailing Address - Street 2:#A20
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5029
Mailing Address - Country:US
Mailing Address - Phone:201-963-3331
Mailing Address - Fax:
Practice Address - Street 1:75 LIBERTY AVE
Practice Address - Street 2:#A20
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-5029
Practice Address - Country:US
Practice Address - Phone:201-963-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00408400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist