Provider Demographics
NPI:1598253940
Name:WILSON, CORRINE MARIE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:CORRINE
Middle Name:MARIE
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 1:1415 PORTLAND AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3022
Mailing Address - Country:US
Mailing Address - Phone:585-922-3653
Mailing Address - Fax:585-922-4200
Practice Address - Street 1:1415 PORTLAND AVE STE 400
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3022
Practice Address - Country:US
Practice Address - Phone:585-922-3653
Practice Address - Fax:585-922-4200
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079034104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker