Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 12005 | IA |
Y | 1041C0700X | Clinical Social Worker | 007700 | IA |
NPI | 1003227299 |
---|---|
Provider Name | Cynthia Sue Wilson |
First Address | Fort Dodge, IA 50501-0466 |
Second Address | Fort Dodge, IA 50501-0466 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/05/2014 |
Last Update Date | 11/05/2014 |