Basic Information
| Provider Information | |||||||||
| NPI: | 1912215948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RICHARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 84 MAIN ST. | ||||||||
| Address2: | PO BOX 179 | ||||||||
| City: | NEWFIELDS | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038560179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034989154 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15 UNION ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018401866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786884830 | ||||||||
| FaxNumber: | 9786884901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2010 | ||||||||
| LastUpdateDate: | 06/11/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.