Provider Demographics
NPI:1861023681
Name:WILSON, OCTAVIA
Entity Type:Individual
Prefix:
First Name:OCTAVIA
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 1:181 STILES ST APT A17
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-1835
Mailing Address - Country:US
Mailing Address - Phone:202-321-9860
Mailing Address - Fax:
Practice Address - Street 1:181 STILES ST APT A17
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1835
Practice Address - Country:US
Practice Address - Phone:202-321-9860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator