Provider Demographics
NPI:1497160998
Name:WILSON, MICHELLE (MED LPCC, LADC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2217
Mailing Address - Country:US
Mailing Address - Phone:218-422-6119
Mailing Address - Fax:218-227-5377
Practice Address - Street 1:1132 28TH AVE S
Practice Address - Street 2:SUITE 102
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4420
Practice Address - Country:US
Practice Address - Phone:218-422-6119
Practice Address - Fax:218-227-5377
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303851101YA0400X
MN1520101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)