Provider Demographics
NPI:1912923921
Name:WILKINSON, MARY ANGELA (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANGELA
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 WAUKEGAN ROAD
Mailing Address - Street 2:SUITE 213
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025
Mailing Address - Country:US
Mailing Address - Phone:847-724-3450
Mailing Address - Fax:847-998-9156
Practice Address - Street 1:1500 WAUKEGAN ROAD
Practice Address - Street 2:SUITE 213
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025
Practice Address - Country:US
Practice Address - Phone:847-724-3450
Practice Address - Fax:847-998-9156
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
983610Medicare ID - Type Unspecified