Provider Demographics
NPI:1881330736
Name:WILSON, OLIVIA A
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:A
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 1:273 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-3421
Mailing Address - Country:US
Mailing Address - Phone:201-705-7789
Mailing Address - Fax:
Practice Address - Street 1:899 MOUNTAIN AVE STE 1A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3403
Practice Address - Country:US
Practice Address - Phone:973-218-6394
Practice Address - Fax:973-218-6351
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00907700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty