Provider Demographics
NPI:1487259388
Name:WILSON, EBONI
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 TEMPLEHURST PL
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-3770
Mailing Address - Country:US
Mailing Address - Phone:937-267-0617
Mailing Address - Fax:
Practice Address - Street 1:6708 TEMPLEHURST PL
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-3770
Practice Address - Country:US
Practice Address - Phone:937-267-0617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2023-01-19
Deactivation Date:2022-11-16
Deactivation Code:
Reactivation Date:2022-11-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid