Provider Demographics
NPI:1053329235
Name:WILSON, KENNETH G (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 E 53RD ST
Mailing Address - Street 2:SUITE 716
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4557
Mailing Address - Country:US
Mailing Address - Phone:312-619-3985
Mailing Address - Fax:773-326-0871
Practice Address - Street 1:1525 E 53RD ST
Practice Address - Street 2:SUITE 716
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4557
Practice Address - Country:US
Practice Address - Phone:312-619-3985
Practice Address - Fax:773-326-0871
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149 0103091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06535Medicare ID - Type Unspecified