Basic Information
| Provider Information | |||||||||
| NPI: | 1124659024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON-LEIGH | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628962210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189376483 | ||||||||
| FaxNumber: | 6189371440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975336 | ||||||||
| FaxNumber: | 6189932969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2020 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 149.024338 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.