Healthcare Provider Details

I. General information

NPI: 1134938095
Provider Name (Legal Business Name): MADISON ANNE MARIE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7423 TIFFANY S
YOUNGSTOWN OH
44514-3908
US

IV. Provider business mailing address

804 ROBBINS AVE
NILES OH
44446-2432
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-2955
  • Fax:
Mailing address:
  • Phone: 330-974-3029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number191167
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: