Provider Demographics
NPI:1437594652
Name:WILSON, POLLY ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44000 W 12 MILE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2646
Mailing Address - Country:US
Mailing Address - Phone:248-226-3001
Mailing Address - Fax:248-347-6479
Practice Address - Street 1:17250 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3151
Practice Address - Country:US
Practice Address - Phone:734-425-4070
Practice Address - Fax:734-425-8350
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011170151041C0700X
MI6802087126104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical