Provider Demographics
NPI:1801518568
Name:WILSON, MAIA (MA, NCC)
Entity type:Individual
Prefix:
First Name:MAIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 W BEACH AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2219
Mailing Address - Country:US
Mailing Address - Phone:541-653-6733
Mailing Address - Fax:
Practice Address - Street 1:3047 N LINCOLN AVE UNIT 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4274
Practice Address - Country:US
Practice Address - Phone:541-653-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health