Provider Demographics
NPI:1144757220
Name:WILSON-EVEREST, MIKA JO (LBSW)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:JO
Last Name:WILSON-EVEREST
Suffix:
Gender:F
Credentials:LBSW
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 398
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49734-0398
Mailing Address - Country:US
Mailing Address - Phone:989-732-6448
Mailing Address - Fax:989-731-0670
Practice Address - Street 1:405 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1859
Practice Address - Country:US
Practice Address - Phone:989-732-6448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085495104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker