Provider Demographics
NPI:1205695939
Name:WILSON, SYDNEY AUTUMN CHANTEL
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:AUTUMN CHANTEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 HWY 35 # 284
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 SEASONS PKWY
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093
Practice Address - Country:US
Practice Address - Phone:470-992-3983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician