Provider Demographics
NPI:1558945725
Name:WILSON, STEPHANIE JEAN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEAN
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 1:516 FENWICK DR
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:SC
Mailing Address - Zip Code:29388-8052
Mailing Address - Country:US
Mailing Address - Phone:724-393-7847
Mailing Address - Fax:
Practice Address - Street 1:516 FENWICK DR
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-8052
Practice Address - Country:US
Practice Address - Phone:724-393-7847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003394103K00000X
1-21-47111103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst