1376968420 NPI number — RENEE CLARESA WILSON LCSWR

Table of content: RENEE CLARESA WILSON LCSWR (NPI 1376968420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376968420 NPI number — RENEE CLARESA WILSON LCSWR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
RENEE
Provider Middle Name:
CLARESA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSWR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376968420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 BEACH 105TH STREET APT.1 D
Provider Second Line Business Mailing Address:
ROCCKAWAY PARK
Provider Business Mailing Address City Name:
N.Y.
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-945-2084
Provider Business Mailing Address Fax Number:
347-923-3368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 COURT STREET
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
BROOKLYN,N.Y.
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-893-1105
Provider Business Practice Location Address Fax Number:
347-923-3368
Provider Enumeration Date:
02/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R035531 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 518217 . This is a "MHN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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