Provider Demographics
NPI:1952467714
Name:WILSON, BETH G (LICSW)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CROSSROADS COUNSELING INC
Mailing Address - Street 2:219 WASHINGTON ST
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:781-431-2277
Mailing Address - Fax:781-431-7770
Practice Address - Street 1:CROSSROADS COUNSELING INC
Practice Address - Street 2:219 WASHINGTON ST
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-431-2277
Practice Address - Fax:781-431-7770
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW106007104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
P10173Medicare UPIN
MAP10173Medicare ID - Type Unspecified