Provider Demographics
NPI:1407490808
Name:WILSON, LATONYA (LLMSW)
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 TORREY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3327
Mailing Address - Country:US
Mailing Address - Phone:810-494-7180
Mailing Address - Fax:248-692-4936
Practice Address - Street 1:2200 GENOA BUSINESS PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-5328
Practice Address - Country:US
Practice Address - Phone:810-449-7180
Practice Address - Fax:248-692-4936
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6801159101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003247362Medicaid