Provider Demographics
NPI:1497025340
Name:WILSON, SHARISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHARISE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2231
Mailing Address - Country:US
Mailing Address - Phone:917-434-5956
Mailing Address - Fax:
Practice Address - Street 1:910 W END AVE
Practice Address - Street 2:1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3533
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-932-0964
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017156103T00000X
NY019779103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03548198Medicaid
NY03548198Medicaid