Healthcare Provider Details

I. General information

NPI: 1760794291
Provider Name (Legal Business Name): CELIA WILSON MA, OC PSII, CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 E 153RD STREET
CLEVELAND OH
44128-1174
US

IV. Provider business mailing address

PO BOX 202644
CLEVELAND OH
44120-8127
US

V. Phone/Fax

Practice location:
  • Phone: 440-317-2496
  • Fax:
Mailing address:
  • Phone: 440-317-2496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number080581
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number1094-C08
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: