Healthcare Provider Details

I. General information

NPI: 1043340334
Provider Name (Legal Business Name): NAOMI WILANSKY MSS LCSW BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BEECH ST BLDG 10
NORMAL IL
61761-1456
US

IV. Provider business mailing address

1100 BEECH ST BLDG 10
NORMAL IL
61761-1456
US

V. Phone/Fax

Practice location:
  • Phone: 309-825-8818
  • Fax: 309-452-1265
Mailing address:
  • Phone: 309-825-8818
  • Fax: 309-452-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008716
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: