Provider Demographics
NPI:1639853013
Name:WILSON, CHARRISSE LEIANA (LCSW)
Entity type:Individual
Prefix:
First Name:CHARRISSE
Middle Name:LEIANA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-8611
Mailing Address - Country:US
Mailing Address - Phone:718-506-1115
Mailing Address - Fax:
Practice Address - Street 1:211 E 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1405
Practice Address - Country:US
Practice Address - Phone:718-506-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical