Provider Demographics
NPI:1821362286
Name:WILSON, THERESA O (LISW-S, SAP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:O
Last Name:WILSON
Suffix:
Gender:F
Credentials:LISW-S, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:130 1ST ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-5452
Practice Address - Country:US
Practice Address - Phone:330-833-0234
Practice Address - Fax:330-837-7705
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1000025-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical