Provider Demographics
NPI:1770248676
Name:WILSON, BIANCA MARIE
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3318 GROVEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-1260
Mailing Address - Country:US
Mailing Address - Phone:440-650-7215
Mailing Address - Fax:
Practice Address - Street 1:LIFE ENHANCEMENT SERVICES
Practice Address - Street 2:4415 EUCLID AVE SUITE 335
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103
Practice Address - Country:US
Practice Address - Phone:216-331-3153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator