Provider Demographics
NPI:1558095927
Name:WILSON, AUDREY J (LMSW)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 E 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5589
Mailing Address - Country:US
Mailing Address - Phone:718-579-5497
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-5497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY114893-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker