1548313281 NPI number — DR. BRUCE LESLIE WILSON PH.D.

Table of content: DR. BRUCE LESLIE WILSON PH.D. (NPI 1548313281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548313281 NPI number — DR. BRUCE LESLIE WILSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
BRUCE
Provider Middle Name:
LESLIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1548313281
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2526
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIARCLIFF MANOR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10510-8126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-666-0060
Provider Business Mailing Address Fax Number:
914-666-9662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
153 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MOUNT KISCO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10549-2317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-666-0060
Provider Business Practice Location Address Fax Number:
914-666-9662
Provider Enumeration Date:
01/18/2007

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: 103TB0200X , with the licence number:  0096961 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 009606 , 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: 6152362 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: S096065 . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 113511 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0078820 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: WS1191 . This is a "OXFORD HEALTH PLANS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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