Provider Demographics
NPI:1003987736
Name:WILSON, MICHELE YVONNE (MSED)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:YVONNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 W LAGUNA RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68522-1153
Mailing Address - Country:US
Mailing Address - Phone:402-525-0733
Mailing Address - Fax:
Practice Address - Street 1:2210 W LAGUNA RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68522-1153
Practice Address - Country:US
Practice Address - Phone:402-525-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE407101YA0400X
NE1681101YM0800X
NE1017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025441800Medicaid
NE85542OtherBLUE CROSS BLUE SHIELD