Provider Demographics
NPI:1760794291
Name:WILSON, CELIA (MA, OC PSII, CDCA)
Entity Type:Individual
Prefix:
First Name:CELIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, OC PSII, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 202644
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-8127
Mailing Address - Country:US
Mailing Address - Phone:440-317-2496
Mailing Address - Fax:
Practice Address - Street 1:3905 E 153RD STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-1174
Practice Address - Country:US
Practice Address - Phone:440-317-2496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1094-C08174H00000X
OH080581101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)