=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245693506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LONI AMANDA WILSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2016
-----------------------------------------------------
Last Update Date | 04/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 W STATE ST SUITE 5
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61101-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-969-8836
-----------------------------------------------------
Fax | 815-969-8871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 321 W STATE ST SUITE 5
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61101-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-969-8836
-----------------------------------------------------
Fax | 815-969-8871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.018037
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------