Individual
MARISA WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MS LBS
Contact information
Practice address
1106 EASTON RD, RIEGELSVILLE, PA 18077-8013
(484) 769-6091
Mailing address
1106 EASTON RD, RIEGELSVILLE, PA 18077-8013
(484) 769-6091
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
BH004434
COMMONWEALTH OF PA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL
PA
Enumeration date
12/29/2020
Last updated
12/29/2020
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