Provider Demographics
NPI:1003151457
Name:WILSON, MICHELE (BACHELORS)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:BACHELORS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 ATWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3223
Mailing Address - Country:US
Mailing Address - Phone:401-724-8400
Mailing Address - Fax:401-722-5280
Practice Address - Street 1:1516 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3223
Practice Address - Country:US
Practice Address - Phone:401-724-8400
Practice Address - Fax:401-722-5280
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid