Provider Demographics
NPI:1417580481
Name:WILSON, BETTY JEAN (LICDC-CS)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:JEAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2447 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-3531
Mailing Address - Country:US
Mailing Address - Phone:419-255-4444
Mailing Address - Fax:
Practice Address - Street 1:2447 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-3531
Practice Address - Country:US
Practice Address - Phone:419-255-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH913005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH913005OtherPROVIDER LICENSE LICDC-CS