Provider Demographics
NPI:1518317890
Name:WILSON, SIMONE (MSW, LLMSW, CAADC-DP)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW, LLMSW, CAADC-DP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27300 FRANKLIN RD APT 720
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2311
Mailing Address - Country:US
Mailing Address - Phone:313-316-4440
Mailing Address - Fax:
Practice Address - Street 1:20411 W 12 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6404
Practice Address - Country:US
Practice Address - Phone:866-703-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 247200000X
MI68011021611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other