MEDICARE: DESTINY CALLAHAM-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	171W00000X	Contractor		MI

General Provider Information

NPI Number	:	1437088051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY CALLAHAM-WILSON

Provider Business Mailing Address
First Line	:	8115 INDIANA ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-3281
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8115 INDIANA ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-3281
Country	:	US
Telephone Number	:	313-288-0976
Fax Number	:

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

Provider Enumeration Date	:	05/18/2026
Last Update Date	:	05/18/2026

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Directions to “ DESTINY CALLAHAM-WILSON ” Practice Location

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