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General NPI Number Information
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NPI Number | 1174255830
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Entity Type | Organization
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Legal Business Name | TAMMY SUE WILSON
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Dates
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Enumeration Date | 06/29/2022
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Last Update Date | 10/21/2024
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Provider Practice Location Address
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Address Line | 3115 LAPEER RD STE A
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City | PORT HURON
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State | MI
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Zip | 48060-7309
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Country | US
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Telephone | 810-637-1183
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Fax | 810-637-1183
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Provider Business Mailing Address
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Address Line | 3115 LAPEER RD STE A
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City | PORT HURON
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State | MI
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Zip | 48060-7309
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Country | US
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Telephone | 810-637-1183
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Fax | 810-637-1183
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | TAMMY SUE WILSON
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Credential | LPC, NCC, RPT, ICST
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Telephone | 810-637-1183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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