Provider Demographics
NPI:1679118822
Name:WILSON, RONNIE JAMES JR
Entity Type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:JAMES
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 W WASHINGTON ST APT B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-7002
Mailing Address - Country:US
Mailing Address - Phone:217-801-4202
Mailing Address - Fax:
Practice Address - Street 1:935 W WASHINGTON ST APT B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-7002
Practice Address - Country:US
Practice Address - Phone:217-801-4202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician