Provider Demographics
NPI:1275112831
Name:WILSON, SUZETTE E
Entity Type:Individual
Prefix:
First Name:SUZETTE
Middle Name:E
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 1:6196 W STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46160-8449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6196 W STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:IN
Practice Address - Zip Code:46160-8449
Practice Address - Country:US
Practice Address - Phone:317-752-7359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20123489106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician