Provider Demographics
NPI:1891806691
Name:WILE, JEROME R (LCSW)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:R
Last Name:WILE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 GREENWICH AVE
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-2701
Mailing Address - Country:US
Mailing Address - Phone:212-255-5075
Mailing Address - Fax:212-255-4937
Practice Address - Street 1:33 GREENWICH AVE
Practice Address - Street 2:SUITE 2D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-2701
Practice Address - Country:US
Practice Address - Phone:212-255-5075
Practice Address - Fax:212-255-4937
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0237691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNO7001Medicare ID - Type Unspecified