Healthcare Provider Details

I. General information

NPI: 1114466372
Provider Name (Legal Business Name): SUSAN KAY WILSON LISW-S, IMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 SUPERIOR DR
HURON OH
44839-1454
US

IV. Provider business mailing address

919 SUPERIOR DR
HURON OH
44839-1454
US

V. Phone/Fax

Practice location:
  • Phone: 440-897-0950
  • Fax:
Mailing address:
  • Phone: 440-897-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI7678
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberF111
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: