Healthcare Provider Details

I. General information

NPI: 1881552008
Provider Name (Legal Business Name): KEISHA MICHELLE WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 01/15/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17052 GREENBAY AVE
LANSING IL
60438-1129
US

IV. Provider business mailing address

17052 GREENBAY AVE
LANSING IL
60438-1129
US

V. Phone/Fax

Practice location:
  • Phone: 312-856-5937
  • Fax:
Mailing address:
  • Phone: 312-856-5937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.030683
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: