Provider Demographics
NPI:1174833750
Name:WILSON, DOUGLAS ALAN (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17224 VAN WAGONER RD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9702
Mailing Address - Country:US
Mailing Address - Phone:231-799-8182
Mailing Address - Fax:616-296-2148
Practice Address - Street 1:17224 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:231-799-8182
Practice Address - Fax:616-296-2148
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012170101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional