Provider Demographics
NPI:1427358993
Name:WILSON, TROVER GRAY (MSW/LCSW/CADC/CODP)
Entity Type:Individual
Prefix:
First Name:TROVER
Middle Name:GRAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW/LCSW/CADC/CODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6033 N SHERIDAN RD APT 19AB
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3003
Mailing Address - Country:US
Mailing Address - Phone:773-373-9175
Mailing Address - Fax:320-205-1753
Practice Address - Street 1:5214 N WESTERN AVE STE 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2592
Practice Address - Country:US
Practice Address - Phone:773-373-9175
Practice Address - Fax:320-205-1753
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490159151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL47-5559459OtherEIN