MEDICARE: CAROLINE COREY WILSON QMHP

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	104100000X	Social Worker
2	171M00000X	Case Manager/Care Coordinator		CA
3	1041C0700X	Clinical Social Worker	T.2405899	OH

General Provider Information

NPI Number	:	1467792879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLINE COREY WILSON QMHP

Provider Business Mailing Address
First Line	:	2310 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1131
Country	:	US
Telephone Number	:	312-477-6766
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1131
Country	:	US
Telephone Number	:	312-477-6766
Fax Number	:

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

Provider Enumeration Date	:	02/21/2013
Last Update Date	:	01/02/2025

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