Provider Demographics
NPI:1508536277
Name:WILSON, MICAELA BARRETT (LAC)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:BARRETT
Last Name:WILSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 NEWTOWN YARDLEY RD STE 214
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-4501
Mailing Address - Country:US
Mailing Address - Phone:215-589-9184
Mailing Address - Fax:
Practice Address - Street 1:770 NEWTOWN YARDLEY RD STE 214
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-4501
Practice Address - Country:US
Practice Address - Phone:720-230-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000332171100000X
COACU.0002705171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist