Healthcare Provider Details

I. General information

NPI: 1760822332
Provider Name (Legal Business Name): WILLIE CARSON LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

IV. Provider business mailing address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

V. Phone/Fax

Practice location:
  • Phone: 269-387-8230
  • Fax: 269-387-7026
Mailing address:
  • Phone: 269-387-8230
  • Fax: 269-387-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberC0714
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: