Basic Information
| Provider Information | |||||||||
| NPI: | 1215503545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOLIZ-QUIROGA | ||||||||
| FirstName: | WILSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BALL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566571 | ||||||||
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| Practice Location | |||||||||
| Address1: | 96 S DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494219004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162861548 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6801106548 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.