Provider Demographics
NPI:1780365064
Name:WILSON, JULIAN C III
Entity type:Individual
Prefix:
First Name:JULIAN
Middle Name:C
Last Name:WILSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-2033
Mailing Address - Country:US
Mailing Address - Phone:134-725-5190
Mailing Address - Fax:
Practice Address - Street 1:164 ELIZABETH STREET
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG, PENNSYLVANIA, UNITED S
Practice Address - State:PA
Practice Address - Zip Code:18301-2033
Practice Address - Country:US
Practice Address - Phone:347-255-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH006127106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst