Provider Demographics
NPI:1255495628
Name:WILSON, DIANNE MARIE (BHU-HS)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:BHU-HS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 BIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MI
Mailing Address - Zip Code:49082-9412
Mailing Address - Country:US
Mailing Address - Phone:231-557-9348
Mailing Address - Fax:
Practice Address - Street 1:1617 E MILHAM AVER
Practice Address - Street 2:SUITE B
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002
Practice Address - Country:US
Practice Address - Phone:269-303-5931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst