Provider Demographics
NPI:1497442206
Name:WILSON, ELAINE HENRIETTA (EDSPC, LMSW /LPC/MAC)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:HENRIETTA
Last Name:WILSON
Suffix:
Gender:F
Credentials:EDSPC, LMSW /LPC/MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1938 COMPTON DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-6629
Mailing Address - Country:US
Mailing Address - Phone:648-531-8036
Mailing Address - Fax:
Practice Address - Street 1:9930 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2036
Practice Address - Country:US
Practice Address - Phone:648-531-8036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000467101YM0800X, 101YP2500X
MI6801059944104100000X, 1041C0700X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171400000XOther Service ProvidersHealth & Wellness Coach