Provider Demographics
NPI:1053160820
Name:WILSON, KENDRICKE DUVAUGHN
Entity type:Individual
Prefix:
First Name:KENDRICKE
Middle Name:DUVAUGHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-3435
Mailing Address - Country:US
Mailing Address - Phone:973-625-1998
Mailing Address - Fax:973-625-8048
Practice Address - Street 1:25 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-3435
Practice Address - Country:US
Practice Address - Phone:973-625-1998
Practice Address - Fax:973-625-8048
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)