MEDICARE: TOYA WILSON D.D

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	101YP1600X	Pastoral Counselor

General Provider Information

NPI Number	:	1760045421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOYA WILSON D.D

Provider Business Mailing Address
First Line	:	1472 RED TOP LN
Second Line	:
City	:	MINOOKA
State	:	IL
Zip	:	60447-8212
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1136 S DELANO CT W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-3740
Country	:	US
Telephone Number	:	773-231-0724
Fax Number	:

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

Provider Enumeration Date	:	04/18/2019
Last Update Date	:	04/18/2019

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