Wendy Diane Wilson-Poth, PH.D.
Individual provider Active NPI Clinical Psychologist · Netcong, NJ
NPI 1912439738 · NPPES record last updated Dec 10, 2019
Key facts
- NPI
- 1912439738
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Clinical Psychologist 103TC0700X
- License
- 38218 (TX)
- Practice address
- 111 Allen St
Netcong, NJ 07857-1222 - Phone
- (973) 527-4464
- NPI assigned
- Mar 30, 2017
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NJ, TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20170531000872 | NJ | Practitioner - Clinical Psychologist | 7911274691 | Reassigns benefits to 1 organization |
| I20191227001208 | TX | Practitioner - Clinical Psychologist | 7911274691 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| TP: 153-017 | NJ | MD | Clinical Psychologist |
| 38218 | TX | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Archetype Psychological Services, LLC | Current |
Accepting new patients |
Locations
444 Northfield Ave
West Orange, NJ 07052
Phone (646) 820-5477
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | TP: 153-017 | NJ | |
| Clinical Psychologist | 103TC0700X | 38218 | TX | Yes |
Addresses
Primary practice location
111 Allen St
Netcong, NJ 07857-1222
Mailing address
111 Allen St
Netcong, NJ 07857-1222
Phone (973) 527-4464
Other names
- Wendy Diane Wilson
Other providers in Netcong, NJ
All providers in Netcong, NJ · Clinical Psychologist in New Jersey
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 10, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.