Individual
EBONY WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3514 BLAIR AVE, SAINT LOUIS, MO 63107-3717
(314) 216-0088
Mailing address
PO BOX 24754, SAINT LOUIS, MO 63115-0654
(314) 216-0088
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Enumeration date
03/20/2014
Last updated
03/20/2014
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