Provider Demographics
NPI:1912215948
Name:WILSON, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 MAIN ST.
Mailing Address - Street 2:PO BOX 179
Mailing Address - City:NEWFIELDS
Mailing Address - State:NH
Mailing Address - Zip Code:03856-0179
Mailing Address - Country:US
Mailing Address - Phone:603-498-9154
Mailing Address - Fax:
Practice Address - Street 1:15 UNION ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1866
Practice Address - Country:US
Practice Address - Phone:978-688-4830
Practice Address - Fax:978-688-4901
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator