Provider Demographics
NPI:1629407523
Name:WILSON, ANDREA T (MSW/LSW)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:T
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW/LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 SOUTH MAIN RD. #3
Mailing Address - Street 2:THE KIDNEY CENTER AT VINELAND
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360
Mailing Address - Country:US
Mailing Address - Phone:856-692-1600
Mailing Address - Fax:856-692-1615
Practice Address - Street 1:1318 S MAIN RD
Practice Address - Street 2:SUITE 3
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6516
Practice Address - Country:US
Practice Address - Phone:856-692-1600
Practice Address - Fax:856-692-1615
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05265200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker