Provider Demographics
NPI:1013384379
Name:WILSON, MICHAEL (MA COUNSELING)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA COUNSELING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 SW FIR LOOP STE 220
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8025
Mailing Address - Country:US
Mailing Address - Phone:503-608-0796
Mailing Address - Fax:
Practice Address - Street 1:7110 SW FIR LOOP STE 220
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-608-0796
Practice Address - Fax:503-213-5886
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5140101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health