Provider Demographics
NPI:1629130067
Name:WILSON, MICHAEL D (MA,MDIV,CEAP,LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA,MDIV,CEAP,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ALEXANDRA LN
Mailing Address - Street 2:
Mailing Address - City:LONG VALLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07853-3458
Mailing Address - Country:US
Mailing Address - Phone:908-876-5693
Mailing Address - Fax:
Practice Address - Street 1:3 ALEXANDRA LN
Practice Address - Street 2:
Practice Address - City:LONG VALLEY
Practice Address - State:NJ
Practice Address - Zip Code:07853-3458
Practice Address - Country:US
Practice Address - Phone:908-876-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00053700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional