Healthcare Provider Details

I. General information

NPI: 1497442206
Provider Name (Legal Business Name): ELAINE HENRIETTA WILSON EDSPC, LMSW /LPC/MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9930 GREENFIELD RD
DETROIT MI
48227-2036
US

IV. Provider business mailing address

1938 COMPTON DR SE
ATLANTA GA
30315-6629
US

V. Phone/Fax

Practice location:
  • Phone: 648-531-8036
  • Fax:
Mailing address:
  • Phone: 648-531-8036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401000467
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401000467
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801059944
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801059944
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: