Healthcare Provider Details

I. General information

NPI: 1528558574
Provider Name (Legal Business Name): WILSON PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 PLAINFIELD AVE NE STE B
GRAND RAPIDS MI
49525-1050
US

IV. Provider business mailing address

5001 PLAINFIELD AVE NE STE B
GRAND RAPIDS MI
49525-1050
US

V. Phone/Fax

Practice location:
  • Phone: 616-600-1667
  • Fax: 616-805-3613
Mailing address:
  • Phone: 616-600-1667
  • Fax: 616-805-3613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: JAMIE WILSON
Title or Position: PRESIDENT / THERAPIST
Credential: LLP
Phone: 616-600-1667