Provider Demographics
NPI:1932799954
Name:SPANN-WILSON, MAI (LSW)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:
Last Name:SPANN-WILSON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WALNUT ST STE 1017
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2906
Mailing Address - Country:US
Mailing Address - Phone:215-564-0488
Mailing Address - Fax:
Practice Address - Street 1:1601 WALNUT ST STE 1017
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2906
Practice Address - Country:US
Practice Address - Phone:215-564-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health