| Doctor Name: | EBONY WILSON |
| NPI Number: | 1013334622 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 3514 Blair Ave Saint Louis, MO - 631073717 |
| Business Phone Number: | 3142160088 |
| Business Fax Number: | |
| Mailing Address: | Po Box 24754, SAINT LOUIS |
| State: | MO |
| Postal Code: | 631150654 |
| Phone Number: | 3142160088 |
| Fax Number: | |
| NPI Enumeration Date: | 03/20/2014 |
| NPI Last Update Date: | 03/20/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320900000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |