Healthcare Provider Details

I. General information

NPI: 1396520326
Provider Name (Legal Business Name): MISS MACKENZIE HOPE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SYCAMORE RD
DEKALB IL
60115-2483
US

IV. Provider business mailing address

1325 SYCAMORE RD
DEKALB IL
60115-2483
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8616
  • Fax:
Mailing address:
  • Phone: 815-758-8616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: