MEDICARE: NICOLE R WILSON LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2024024817	MO

General Provider Information

NPI Number	:	1083452577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE R WILSON LMSW

Provider Business Mailing Address
First Line	:	PO BOX 844715
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64184-4715
Country	:	US
Telephone Number	:	417-761-5214
Fax Number	:

Provider Business Practice Location Address
First Line	:	1423 N JEFFERSON AVE FL 3
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-1917
Country	:	US
Telephone Number	:	417-761-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2024
Last Update Date	:	02/11/2026

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