Provider Demographics
NPI:1407089725
Name:WILSON, CHERYL DENISE
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:DENISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:DENISE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-0032
Mailing Address - Country:US
Mailing Address - Phone:219-576-4775
Mailing Address - Fax:
Practice Address - Street 1:141 W 46TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-3905
Practice Address - Country:US
Practice Address - Phone:219-614-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker