Basic Information
| Provider Information | |||||||||
| NPI: | 1629331061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | VAL LORIE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1309 5TH AVE | ||||||||
| Address2: | 34B | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100293123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9176915743 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 535 8TH AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100184305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127879700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.