Provider Demographics
NPI:1467792879
Name:WILSON, CAROLINE COREY (QMHP)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:COREY
Last Name:WILSON
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1131
Mailing Address - Country:US
Mailing Address - Phone:312-477-6766
Mailing Address - Fax:
Practice Address - Street 1:2310 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1131
Practice Address - Country:US
Practice Address - Phone:312-477-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA171M00000X
OHT.24058991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator