MEDICARE: MICHAEL WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1164895728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WILSON

Provider Business Mailing Address
First Line	:	3027 PLEASANT GRV
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5758
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3027 PLEASANT GRV
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5758
Country	:	US
Telephone Number	:	318-208-4420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2015
Last Update Date	:	11/04/2015

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Directions to “ MICHAEL WILSON ” Practice Location

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