Provider Demographics
NPI:1194890285
Name:WILSON, SALLY L (PHD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241186
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-8786
Mailing Address - Country:US
Mailing Address - Phone:440-442-9355
Mailing Address - Fax:216-371-2108
Practice Address - Street 1:30500 FAIRMOUNT BLVD STE 9
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-4802
Practice Address - Country:US
Practice Address - Phone:440-442-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3535103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWICP06191Medicare ID - Type UnspecifiedMEDICARE