MEDICARE: MS. ANGELIQUE EMILY 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	104100000X	Social Worker
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1851168801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELIQUE EMILY WILSON

Provider Business Mailing Address
First Line	:	6030 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7639
Country	:	US
Telephone Number	:	260-245-6374
Fax Number	:

Provider Business Practice Location Address
First Line	:	6030 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7639
Country	:	US
Telephone Number	:	260-245-6374
Fax Number	:

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

Provider Enumeration Date	:	12/11/2023
Last Update Date	:	12/11/2023

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