Provider Demographics
NPI:1891366548
Name:WILSON, GILLIAN (PHD)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 W 13TH ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-7803
Mailing Address - Country:US
Mailing Address - Phone:929-457-1452
Mailing Address - Fax:
Practice Address - Street 1:175 W 13TH ST APT 1B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7803
Practice Address - Country:US
Practice Address - Phone:929-457-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025196103TC0700X
NYP103064390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program