Provider Demographics
NPI:1003227299
Name:WILSON, CYNTHIA SUE (LISW, CADC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LISW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-0466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:728 1ST AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-0466
Practice Address - Country:US
Practice Address - Phone:515-571-1724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-11
Last Update Date:2014-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12005101YA0400X
IA0077001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)