Provider Demographics
NPI:1518577519
Name:WILSON, NASTASSJA
Entity Type:Individual
Prefix:
First Name:NASTASSJA
Middle Name:
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 1:558 BEACH 65TH ST
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1329
Mailing Address - Country:US
Mailing Address - Phone:347-204-2034
Mailing Address - Fax:
Practice Address - Street 1:558 BEACH 65TH ST
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1329
Practice Address - Country:US
Practice Address - Phone:347-204-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical