Provider Demographics
NPI:1326133752
Name:WILSON, EDWARD ARTHUR (LCSW-R)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ARTHUR
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 KENT STREET
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:13865
Mailing Address - Country:US
Mailing Address - Phone:607-655-5332
Mailing Address - Fax:
Practice Address - Street 1:DELAWARE COUNTY MENTAL HEALTH CLINIC
Practice Address - Street 2:ONE HOSPITAL ROAD
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856
Practice Address - Country:US
Practice Address - Phone:607-865-6522
Practice Address - Fax:607-865-7424
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073293-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNE1491Medicare ID - Type Unspecified