Healthcare Provider Details

I. General information

NPI: 1235423104
Provider Name (Legal Business Name): KATHRYN WILSON P.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FORD PL STE 1F
DETROIT MI
48202-3450
US

IV. Provider business mailing address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

V. Phone/Fax

Practice location:
  • Phone: 313-874-4907
  • Fax:
Mailing address:
  • Phone: 616-840-8000
  • Fax: 616-840-9762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number6301014211
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301014211
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: