Basic Information
| Provider Information | |||||||||
| NPI: | 1831475680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | YVONNE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38902 HOUSTON DR | ||||||||
| Address2: | |||||||||
| City: | ROMULUS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481745052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133330916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20500 EUREKA RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481806332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342858282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401011576 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1831475680 | 05 | MI | MEDICAID |