Healthcare Provider Details

I. General information

NPI: 1326751215
Provider Name (Legal Business Name): RACHEL MARYANNA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 TROWBRIDGE ST NE APT 208
GRAND RAPIDS MI
49503-1891
US

IV. Provider business mailing address

649 EVANS ST SE
GRAND RAPIDS MI
49503-4738
US

V. Phone/Fax

Practice location:
  • Phone: 616-209-9295
  • Fax:
Mailing address:
  • Phone: 616-914-8508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851110205
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: