Provider Demographics
NPI:1417523846
Name:WILSON, TAYLOR RENEE (LLMSW)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RENEE
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 1:3621 FAWN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-6837
Mailing Address - Country:US
Mailing Address - Phone:616-610-1281
Mailing Address - Fax:
Practice Address - Street 1:3621 FAWN VIEW DR
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-6837
Practice Address - Country:US
Practice Address - Phone:616-610-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801109766101Y00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor