Provider Demographics
NPI:1043239379
Name:WILSON, JUDY M (MSW/LISW)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW/LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 BLACKJACK ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-9193
Mailing Address - Country:US
Mailing Address - Phone:740-397-0442
Mailing Address - Fax:740-392-1814
Practice Address - Street 1:8402 BLACKJACK ROAD EXT
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9193
Practice Address - Country:US
Practice Address - Phone:740-397-0442
Practice Address - Fax:740-392-1814
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00051211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical