Provider Demographics
NPI:1548313281
Name:WILSON, BRUCE LESLIE (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LESLIE
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:BRIARCLIFF MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10510-8126
Mailing Address - Country:US
Mailing Address - Phone:914-666-0060
Mailing Address - Fax:914-666-9662
Practice Address - Street 1:153 E MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-2317
Practice Address - Country:US
Practice Address - Phone:914-666-0060
Practice Address - Fax:914-666-9662
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0096961103TB0200X
NY009606103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6152362OtherUNITED BEHAVIORAL HEALTH
NYS096065OtherWORKERS COMPENSATION
NY113511OtherVALUE OPTIONS
NY0078820OtherGHI
NYWS1191OtherOXFORD HEALTH PLANS
NY6152362OtherUNITED BEHAVIORAL HEALTH