Healthcare Provider Details

I. General information

NPI: 1306358247
Provider Name (Legal Business Name): SUSAN WILSON LMSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 HORTON RD STE 3
JACKSON MI
49203-5599
US

IV. Provider business mailing address

8640 HEATHER LN
ONSTED MI
49265-9744
US

V. Phone/Fax

Practice location:
  • Phone: 734-425-0396
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801068911
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: