MEDICARE: MARIE WILSON, LLC

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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1669213070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIE WILSON, LLC

Provider Business Mailing Address
First Line	:	647 GLADSTONE DR SE
Second Line	:
City	:	EAST GRAND RAPIDS
State	:	MI
Zip	:	49506-2818
Country	:	US
Telephone Number	:	616-475-7722
Fax Number	:

Provider Business Practice Location Address
First Line	:	647 GLADSTONE DR SE
Second Line	:
City	:	EAST GRAND RAPIDS
State	:	MI
Zip	:	49506-2818
Country	:	US
Telephone Number	:	616-475-7722
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARIE WILSON
Credential	:
Telephone Number	:	616-475-7722

Provider Enumeration Date	:	06/03/2024
Last Update Date	:	04/18/2025

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