MEDICARE: MICHELE L WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH12108	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MH12108	OTHER	FL	LICENSE

General Provider Information

NPI Number	:	1205231404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHELE L WILSON

Provider Business Mailing Address
First Line	:	6054 HOLLYWOOD STREET
Second Line	:
City	:	JUPITER
State	:	FL
Zip	:	33458-6724
Country	:	US
Telephone Number	:	561-308-0814
Fax Number	:	561-444-4444

Provider Business Practice Location Address
First Line	:	400 VILLAGE SQUARE XING
Second Line	:	SUITE 2
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-3227
Country	:	US
Telephone Number	:	561-308-0814
Fax Number	:	561-444-4444

Authorized Official
Title or Position	:	PROVIDER & OWNER
Name	:	MICHELE L WILSON
Credential	:	LMHC CAP
Telephone Number	:	561-308-0814

Provider Enumeration Date	:	10/30/2014
Last Update Date	:	10/30/2014

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