Provider Demographics
NPI:1124201272
Name:WILSON, MICHELLE J (RPT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 891
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725-0891
Mailing Address - Country:US
Mailing Address - Phone:410-571-6411
Mailing Address - Fax:410-571-6415
Practice Address - Street 1:190 ADMIRAL COCHRANE DR
Practice Address - Street 2:SUITE 180
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7365
Practice Address - Country:US
Practice Address - Phone:410-571-6411
Practice Address - Fax:410-571-6415
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist