=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851565568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. CORNELIUS AL WILSON JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2008
-----------------------------------------------------
Last Update Date | 04/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15805 BAYLIS ST STE # 101
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48238-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-341-1777
-----------------------------------------------------
Fax | 313-521-0228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5440 CASS AVE STE # 1209
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-3668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-942-2803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------