Provider Demographics
NPI:1861653347
Name:WILSON, SCOTT T (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:T
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 RIVERSIDE DR
Mailing Address - Street 2:UNIT 42
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:514 W END AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-4337
Practice Address - Country:US
Practice Address - Phone:917-647-9609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68016303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical