Provider Demographics
NPI:1114961265
Name:WILSON, CATHERINE S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E RANDOLPH ST
Mailing Address - Street 2:APT 3304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7418
Mailing Address - Country:US
Mailing Address - Phone:847-226-7114
Mailing Address - Fax:
Practice Address - Street 1:345 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2654
Practice Address - Country:US
Practice Address - Phone:312-238-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL91817Medicare UPIN
IL1114961265Medicare UPIN
ILK29764Medicare UPIN