Provider Demographics
NPI:1225133069
Name:WILSON, MARIE JOYCE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:JOYCE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:JOYCE
Other - Last Name:GALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:529 GREENWOOD AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2909
Mailing Address - Country:US
Mailing Address - Phone:616-475-7722
Mailing Address - Fax:616-475-7722
Practice Address - Street 1:529 GREENWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2909
Practice Address - Country:US
Practice Address - Phone:616-475-7722
Practice Address - Fax:616-475-7722
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010627741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM55940Medicare ID - Type Unspecified