MEDICARE: MR. JOHN DOUGLAS WILSON M.S.W.

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	1041C0700X	Clinical Social Worker	6801016033	MI
2	1041C0700X	Clinical Social Worker	149.012903	IL

General Provider Information

NPI Number	:	1841507316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN DOUGLAS WILSON M.S.W.

Provider Business Mailing Address
First Line	:	3611 ROCHESTER RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48073-2816
Country	:	US
Telephone Number	:	248-765-4512
Fax Number	:

Provider Business Practice Location Address
First Line	:	3611 ROCHESTER RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48073-2816
Country	:	US
Telephone Number	:	248-765-4512
Fax Number	:

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

Provider Enumeration Date	:	09/07/2010
Last Update Date	:	09/07/2010

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