Provider Demographics
NPI:1376968420
Name:WILSON, RENEE CLARESA (LCSWR)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:CLARESA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BEACH 105TH STREET APT.1 D
Mailing Address - Street 2:ROCCKAWAY PARK
Mailing Address - City:N.Y.
Mailing Address - State:NY
Mailing Address - Zip Code:11694
Mailing Address - Country:US
Mailing Address - Phone:718-945-2084
Mailing Address - Fax:347-923-3368
Practice Address - Street 1:26 COURT STREET
Practice Address - Street 2:SUITE 600
Practice Address - City:BROOKLYN,N.Y.
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:347-893-1105
Practice Address - Fax:347-923-3368
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0355311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY518217OtherMHN