Provider Demographics
NPI:1730461153
Name:WILSON, ADA D (BA)
Entity type:Individual
Prefix:
First Name:ADA
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 B PUTNAM BLVD
Mailing Address - Street 2:APT B
Mailing Address - City:WALLINGFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19086
Mailing Address - Country:US
Mailing Address - Phone:610-876-1458
Mailing Address - Fax:
Practice Address - Street 1:2 BALA PLZ
Practice Address - Street 2:SUITE 300
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1501
Practice Address - Country:US
Practice Address - Phone:610-660-7779
Practice Address - Fax:610-667-8174
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025537100001OtherMA
PA1025537100001Medicaid