Provider Demographics
NPI:1952148157
Name:WILSON, MARVELLICIA ANTOINETTE (RCSWI)
Entity type:Individual
Prefix:MRS
First Name:MARVELLICIA
Middle Name:ANTOINETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RCSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 BONAPARTE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6734
Mailing Address - Country:US
Mailing Address - Phone:571-278-8127
Mailing Address - Fax:
Practice Address - Street 1:645 BONAPARTE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6734
Practice Address - Country:US
Practice Address - Phone:571-278-8127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW203861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical