Provider Demographics
NPI:1164642997
Name:WILSON, MARY KATHLEEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33914 230TH STREET
Mailing Address - Street 2:
Mailing Address - City:BARRY
Mailing Address - State:IL
Mailing Address - Zip Code:62312
Mailing Address - Country:US
Mailing Address - Phone:217-285-4436
Mailing Address - Fax:217-285-2804
Practice Address - Street 1:121 SOUTH MADISON STREET
Practice Address - Street 2:MENTAL HEALTH CENTERS OF WESTERN ILLINOIS
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363
Practice Address - Country:US
Practice Address - Phone:217-285-4436
Practice Address - Fax:217-285-2804
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional