Provider Demographics
NPI:1700909538
Name:WILSON, MARY JO (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:CASTRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:484 W 43RD ST
Mailing Address - Street 2:44-M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-6319
Mailing Address - Country:US
Mailing Address - Phone:212-564-1174
Mailing Address - Fax:
Practice Address - Street 1:315 W 57TH ST
Practice Address - Street 2:SUITE 402
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3158
Practice Address - Country:US
Practice Address - Phone:212-757-6607
Practice Address - Fax:212-757-2932
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010284103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)