Provider Demographics
NPI:1306211792
Name:WILSON, NICHOLAS FREDERICK (BSW,CASAC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:FREDERICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:BSW,CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11630 SUTPHIN BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1527
Mailing Address - Country:US
Mailing Address - Phone:718-322-2500
Mailing Address - Fax:718-322-1881
Practice Address - Street 1:11630 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1527
Practice Address - Country:US
Practice Address - Phone:718-322-2500
Practice Address - Fax:718-322-1881
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20345101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)