Provider Demographics
NPI:1477793271
Name:WILSON, GORDON BRUCE (LCSW)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:BRUCE
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 1:562 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3721
Mailing Address - Country:US
Mailing Address - Phone:570-552-3760
Mailing Address - Fax:570-552-3765
Practice Address - Street 1:562 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3721
Practice Address - Country:US
Practice Address - Phone:570-552-3760
Practice Address - Fax:570-552-3765
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACWO13852101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health