Provider Demographics
NPI:1952680860
Name:WILSON, MARY MAE ABIGAIL (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAE ABIGAIL
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W PLYMOUTH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2745
Mailing Address - Country:US
Mailing Address - Phone:352-234-3804
Mailing Address - Fax:
Practice Address - Street 1:125 W PLYMOUTH AVE STE D
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2745
Practice Address - Country:US
Practice Address - Phone:352-234-3804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW189611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical