Provider Demographics
NPI:1275784837
Name:WAHLQUIST, BAILEY ELIZABETH (MA)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:ELIZABETH
Last Name:WAHLQUIST
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:ELIZABETH
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:141 MARKET PL
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2034
Mailing Address - Country:US
Mailing Address - Phone:618-398-7250
Mailing Address - Fax:618-398-6870
Practice Address - Street 1:141 MARKET PL
Practice Address - Street 2:SUITE 206
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2034
Practice Address - Country:US
Practice Address - Phone:618-398-7250
Practice Address - Fax:618-398-6870
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
12287066OtherCAQH