Healthcare Provider Details

I. General information

NPI: 1629100078
Provider Name (Legal Business Name): MICHAEL E WILSON M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 S MAKIN LN
CANBY OR
97013-9728
US

IV. Provider business mailing address

PO BOX 1003
CANBY OR
97013-1003
US

V. Phone/Fax

Practice location:
  • Phone: 209-648-4894
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT50840
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: