Healthcare Provider Details

I. General information

NPI: 1396805065
Provider Name (Legal Business Name): TAMARA DAWN WILSON LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 E APPLE AVE
MUSKEGON MI
49442-3466
US

IV. Provider business mailing address

1294 PRINCETON RD
MUSKEGON MI
49441-3800
US

V. Phone/Fax

Practice location:
  • Phone: 231-724-1111
  • Fax: 231-724-1300
Mailing address:
  • Phone: 231-755-6014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802059452
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: