Provider Demographics
NPI:1750599445
Name:WILSON, LAURIE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
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 1:175 W 12TH ST
Mailing Address - Street 2:6A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8275
Mailing Address - Country:US
Mailing Address - Phone:212-620-0695
Mailing Address - Fax:
Practice Address - Street 1:175 WEST 12TH STREET
Practice Address - Street 2:6A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-620-0695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000019102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst