Basic Information
| Provider Information | |||||||||
| NPI: | 1245614395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MS, LLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COWLEY | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6425 SCHAEFER RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481261974 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6425 SCHAEFER RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138462606 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2015 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301016297 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.