Provider Demographics
NPI:1841737061
Name:WILSON, TAMMY
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:
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 1:144 KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-9544
Mailing Address - Country:US
Mailing Address - Phone:860-212-7956
Mailing Address - Fax:
Practice Address - Street 1:151 BROAD ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3327
Practice Address - Country:US
Practice Address - Phone:860-346-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002522101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health