MEDICARE: DUANE LOUIS WILSON

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1568344521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUANE LOUIS WILSON

Provider Business Mailing Address
First Line	:	5152 E 114TH ST
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-2866
Country	:	US
Telephone Number	:	216-224-8396
Fax Number	:	216-224-8396

Provider Business Practice Location Address
First Line	:	5152 E 114TH ST
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-2866
Country	:	US
Telephone Number	:	216-224-8396
Fax Number	:	216-224-8396

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

Provider Enumeration Date	:	07/22/2025
Last Update Date	:	07/22/2025

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