Provider Demographics
NPI:1821205444
Name:WILSON, THERESA C (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 DUDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-4426
Mailing Address - Country:US
Mailing Address - Phone:856-541-1700
Mailing Address - Fax:856-488-5530
Practice Address - Street 1:900 DUDLEY AVE
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-4426
Practice Address - Country:US
Practice Address - Phone:856-541-1700
Practice Address - Fax:856-488-5530
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000007001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC00000700OtherSOCIAL WORK LICENSE