Provider Demographics
NPI:1396224010
Name:WILSON, ANGEL (CADC #32962)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CADC #32962
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E WOOD ST STE B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523-1431
Mailing Address - Country:US
Mailing Address - Phone:217-422-6908
Mailing Address - Fax:217-422-7103
Practice Address - Street 1:335 E WOOD ST STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523-1431
Practice Address - Country:US
Practice Address - Phone:217-422-6908
Practice Address - Fax:217-422-7103
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL32962101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)