Provider Demographics
NPI:1740825785
Name:WILSON, CRYSTAL ANGELA (LMSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANGELA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 LORETTA RD FL 2
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2537
Mailing Address - Country:US
Mailing Address - Phone:917-808-1050
Mailing Address - Fax:
Practice Address - Street 1:8974 162ND ST STE 3
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5012
Practice Address - Country:US
Practice Address - Phone:718-526-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10828401104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker