MEDICARE: COURTNEY PAIGE WILSON LCSW

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	149.021778	IL
2	104100000X	Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	149.021778	OTHER	IL	IDFPR

General Provider Information

NPI Number	:	1831697838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY PAIGE WILSON LCSW

Provider Business Mailing Address
First Line	:	4824 N DAMEN AVE APT 401
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1476
Country	:	US
Telephone Number	:	651-368-1792
Fax Number	:

Provider Business Practice Location Address
First Line	:	4824 N DAMEN AVE APT 401
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1476
Country	:	US
Telephone Number	:	651-368-1792
Fax Number	:

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

Provider Enumeration Date	:	01/25/2018
Last Update Date	:	11/15/2019

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