Healthcare Provider Details

I. General information

NPI: 1093257461
Provider Name (Legal Business Name): BENJAMIN RUSSELL WILSON LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6461 DAWN DR
BELLEVUE MI
49021-8411
US

IV. Provider business mailing address

6461 DAWN DR.
BELLEVUE MI
49021
US

V. Phone/Fax

Practice location:
  • Phone: 269-986-2844
  • Fax:
Mailing address:
  • Phone: 269-986-2844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015351
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: