Provider Demographics
NPI:1497809800
Name:WILSON, MICHELLE LEIGH (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 STONEHEDGE RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1251
Mailing Address - Country:US
Mailing Address - Phone:978-475-1617
Mailing Address - Fax:
Practice Address - Street 1:63 PARK ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3662
Practice Address - Country:US
Practice Address - Phone:978-475-1617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health