Provider Demographics
NPI:1326201963
Name:WILSON, JAMES KEVIN (LCSW)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KEVIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 W 43RD ST
Mailing Address - Street 2:44M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-6319
Mailing Address - Country:US
Mailing Address - Phone:212-564-1174
Mailing Address - Fax:
Practice Address - Street 1:65 BROADWAY
Practice Address - Street 2:713
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2503
Practice Address - Country:US
Practice Address - Phone:212-430-3891
Practice Address - Fax:212-430-3892
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR053331-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical