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NPI Code Detail

MEDICARE: MR. TONY D WILSON LCSW

MEDICARE: MR. TONY D WILSON LCSW
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
11041C0700XClinical Social WorkerIL

General Provider Information

NPI Number : 1811170038
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TONY D WILSON LCSW
Provider Business Mailing Address
First Line : 3062 E 91ST ST
Second Line :
City : CHICAGO
State : IL
Zip : 60617-4401
Country : US
Telephone Number : 773-371-2900
Fax Number :
Provider Business Practice Location Address
First Line : 3062 E 91ST ST
Second Line :
City : CHICAGO
State : IL
Zip : 60617-4401
Country : US
Telephone Number : 773-371-2900
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/11/2007
Last Update Date : 12/11/2007

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