Provider Demographics
NPI:1518509926
Name:WILSON, ELIZABETH CHARLENE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CHARLENE
Last Name:WILSON
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 1:989 VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-2119
Mailing Address - Country:US
Mailing Address - Phone:516-477-3096
Mailing Address - Fax:
Practice Address - Street 1:300 CADMAN PLZ W FL 12129
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3229
Practice Address - Country:US
Practice Address - Phone:347-689-7759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012152101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health