Provider Demographics
NPI:1497990691
Name:WILSEY, MARY MARTHA
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MARTHA
Last Name:WILSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:PHOENICIA
Mailing Address - State:NY
Mailing Address - Zip Code:12464
Mailing Address - Country:US
Mailing Address - Phone:845-688-2183
Mailing Address - Fax:
Practice Address - Street 1:89 MAIN ST.
Practice Address - Street 2:
Practice Address - City:PHOENICIA
Practice Address - State:NY
Practice Address - Zip Code:12464
Practice Address - Country:US
Practice Address - Phone:845-688-2183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004558235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist