Provider Demographics
NPI:1639693849
Name:VOGEL-WILSON, THEODORE ERIC
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:ERIC
Last Name:VOGEL-WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-2724
Mailing Address - Country:US
Mailing Address - Phone:309-558-4063
Mailing Address - Fax:
Practice Address - Street 1:931 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-2724
Practice Address - Country:US
Practice Address - Phone:309-558-4063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-29
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107440101YM0800X
IL180015775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health