Provider Demographics
NPI:1902303035
Name:WILSON, SUSAN A (LAC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 PADDINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-3258
Mailing Address - Country:US
Mailing Address - Phone:551-427-3169
Mailing Address - Fax:
Practice Address - Street 1:22-08 ROUTE 208
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2609
Practice Address - Country:US
Practice Address - Phone:201-956-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00381600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health