Provider Demographics
NPI:1598887366
Name:WILSON, MARK OWEN (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:OWEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:OWEN
Other - Last Name:BELUE WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:7125 E US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7968
Mailing Address - Country:US
Mailing Address - Phone:317-272-2190
Mailing Address - Fax:317-272-2199
Practice Address - Street 1:7125 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7968
Practice Address - Country:US
Practice Address - Phone:317-272-2190
Practice Address - Fax:317-272-2199
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003687A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN182920CMedicare ID - Type Unspecified
IN343540Medicare PIN
IN182920Medicare PIN