Provider Demographics
NPI:1437267614
Name:WILSON, JUDY L (PSYD)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:L
Last Name:WILSON
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 1:805 GEORGETOWN DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-6033
Mailing Address - Country:US
Mailing Address - Phone:630-548-4819
Mailing Address - Fax:630-717-8259
Practice Address - Street 1:1112 S WASHINGTON ST STE 112
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7960
Practice Address - Country:US
Practice Address - Phone:630-717-9858
Practice Address - Fax:630-717-8259
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232446OtherBLUECROSSBLUE SHIELD PIN