MEDICARE: DEBRA A WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP1600X	Pastoral Counselor

General Provider Information

NPI Number	:	1154055333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA A WILSON

Provider Business Mailing Address
First Line	:	1259 CARLYON RD
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-4129
Country	:	US
Telephone Number	:	216-482-4626
Fax Number	:

Provider Business Practice Location Address
First Line	:	1259 CARLYON RD
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-4129
Country	:	US
Telephone Number	:	216-482-4626
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2022
Last Update Date	:	07/13/2022

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