Provider Demographics
NPI:1801314141
Name:WILSON, MIA PHYU
Entity type:Individual
Prefix:MRS
First Name:MIA
Middle Name:PHYU
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:PHYU
Other - Last Name:WIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:21 GRIFFIN RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053
Mailing Address - Country:US
Mailing Address - Phone:978-987-1291
Mailing Address - Fax:
Practice Address - Street 1:21 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053
Practice Address - Country:US
Practice Address - Phone:978-987-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist