MEDICARE: MRS. VALETA WILSON LSW

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	33006279A	IN

General Provider Information

NPI Number	:	1871833103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VALETA WILSON LSW

Provider Business Mailing Address
First Line	:	4009 MELVILLE AVE
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2735
Country	:	US
Telephone Number	:	219-805-2941
Fax Number	:

Provider Business Practice Location Address
First Line	:	4009 MELVILLE AVE
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2735
Country	:	US
Telephone Number	:	219-805-2941
Fax Number	:

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

Provider Enumeration Date	:	02/23/2013
Last Update Date	:	02/23/2013

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