Provider Demographics
NPI:1558890772
Name:WILSON, SIMONE (LCSW)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17031 BERNADINE ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-1159
Mailing Address - Country:US
Mailing Address - Phone:708-212-3606
Mailing Address - Fax:
Practice Address - Street 1:17732 OAK PARK AVE STE K
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2064
Practice Address - Country:US
Practice Address - Phone:708-212-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-10
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490190731041C0700X
IL18777191041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool