Healthcare Provider Details

I. General information

NPI: 1336183359
Provider Name (Legal Business Name): RUTH F. WILSON LISW-S, LICDC, SAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14650 DETROIT AVENUE SUITE LL40
LAKEWOOD OH
44107
US

IV. Provider business mailing address

14650 DETROIT AVENUE SUITE LL40
LAKEWOOD OH
44107
US

V. Phone/Fax

Practice location:
  • Phone: 216-226-2721
  • Fax: 216-226-2731
Mailing address:
  • Phone: 216-226-2721
  • Fax: 216-226-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number862270
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI4506
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0004506
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number862270
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: