Healthcare Provider Details

I. General information

NPI: 1710548136
Provider Name (Legal Business Name): VANESSA ANN WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PFEIFFER AVE
KIRKSVILLE MO
63501-5047
US

IV. Provider business mailing address

105 PFEIFFER AVE
KIRKSVILLE MO
63501-5047
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-4612
  • Fax: 660-665-4635
Mailing address:
  • Phone: 660-665-4612
  • Fax: 660-665-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2019021666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: