Provider Demographics
NPI:1558992057
Name:WILSON, STEPHANIE R
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2615 EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3915
Mailing Address - Country:US
Mailing Address - Phone:901-239-8461
Mailing Address - Fax:
Practice Address - Street 1:2615 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3915
Practice Address - Country:US
Practice Address - Phone:901-239-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38674101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA844551151OtherTRANSPORTATION