Healthcare Provider Details

I. General information

NPI: 1811852023
Provider Name (Legal Business Name): MARY MICHELE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 NASA PKWY STE 210
HOUSTON TX
77058-2800
US

IV. Provider business mailing address

1123 WOODHORN DR
HOUSTON TX
77062-2730
US

V. Phone/Fax

Practice location:
  • Phone: 281-508-2205
  • Fax:
Mailing address:
  • Phone: 281-513-9511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number206294
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: