Provider Demographics
NPI:1467703033
Name:WILSON, MARVIN D'ANDRE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:D'ANDRE
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S BURROWES ST
Mailing Address - Street 2:SUITE 607
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-3863
Mailing Address - Country:US
Mailing Address - Phone:814-238-0921
Mailing Address - Fax:814-238-1875
Practice Address - Street 1:119 S BURROWES ST
Practice Address - Street 2:SUITE 607
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-3863
Practice Address - Country:US
Practice Address - Phone:814-238-0921
Practice Address - Fax:814-238-1875
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSO17102103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling