Provider Demographics
NPI:1225126691
Name:WILSON, RICHARD MARSH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARSH
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DANA RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-7043
Mailing Address - Country:US
Mailing Address - Phone:781-416-7764
Mailing Address - Fax:
Practice Address - Street 1:554 WASHINGTON ST
Practice Address - Street 2:SUITE 4
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-6408
Practice Address - Country:US
Practice Address - Phone:781-237-1379
Practice Address - Fax:781-237-1379
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8423103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51420Medicare ID - Type Unspecified