Healthcare Provider Details

I. General information

NPI: 1780294868
Provider Name (Legal Business Name): CORALEEN Y WILSON LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24445 NORTHWESTERN HWY
SOUTHFIELD MI
48075-6501
US

IV. Provider business mailing address

18726 S WESTERN AVE STE 408
GARDENA CA
90248-3858
US

V. Phone/Fax

Practice location:
  • Phone: 248-242-5545
  • Fax: 248-450-0582
Mailing address:
  • Phone: 310-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401226225
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: