Provider Demographics
NPI:1326462623
Name:WILSON, ERIK (GENERAL MANAGER)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:GENERAL MANAGER
Other - Prefix:MR
Other - First Name:ERIK
Other - Middle Name:LAMONT
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MANAGER
Mailing Address - Street 1:29240 BUCKINGHAM
Mailing Address - Street 2:11
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154
Mailing Address - Country:US
Mailing Address - Phone:734-513-2800
Mailing Address - Fax:734-513-3606
Practice Address - Street 1:29240 BUCKINGHAM ST
Practice Address - Street 2:11
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-4575
Practice Address - Country:US
Practice Address - Phone:734-513-2800
Practice Address - Fax:734-513-3606
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI-10191M251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health