Provider Demographics
NPI:1437205283
Name:WILSON, MICHAEL C (MSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 XENIA AVE
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1836
Mailing Address - Country:US
Mailing Address - Phone:937-767-9171
Mailing Address - Fax:937-767-9175
Practice Address - Street 1:416 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1836
Practice Address - Country:US
Practice Address - Phone:937-767-9171
Practice Address - Fax:937-767-9175
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.070004TEMP104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker