Provider Demographics
NPI:1356633259
Name:WILSON, MICHAEL PAUL (MED)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-4248
Mailing Address - Country:US
Mailing Address - Phone:405-638-0312
Mailing Address - Fax:
Practice Address - Street 1:1309 S 13TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-4248
Practice Address - Country:US
Practice Address - Phone:405-638-0312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0542036103TS0200X
OK4678101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool