Provider Demographics
NPI:1912439738
Name:WILSON-POTH, WENDY DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:DIANE
Last Name:WILSON-POTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:DIANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:111 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:NETCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07857-1222
Mailing Address - Country:US
Mailing Address - Phone:973-527-4464
Mailing Address - Fax:
Practice Address - Street 1:111 ALLEN ST
Practice Address - Street 2:
Practice Address - City:NETCONG
Practice Address - State:NJ
Practice Address - Zip Code:07857-1222
Practice Address - Country:US
Practice Address - Phone:973-527-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTP: 153-017103TC0700X
TX38218103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical