Provider Demographics
NPI:1275976896
Name:WILSON, REBECCA ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W VAN BUREN ST STE 470
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3291
Mailing Address - Country:US
Mailing Address - Phone:312-942-3227
Mailing Address - Fax:312-563-2746
Practice Address - Street 1:1700 W VAN BUREN ST STE 470
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3291
Practice Address - Country:US
Practice Address - Phone:312-942-3227
Practice Address - Fax:312-563-2746
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009558103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical