Provider Demographics
NPI:1780848028
Name:WILBANKS, MAEGAN LEA (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:MAEGAN
Middle Name:LEA
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1221
Mailing Address - Country:US
Mailing Address - Phone:618-559-6318
Mailing Address - Fax:
Practice Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5256
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002968172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker