Provider Demographics
NPI:1649208018
Name:WILSON, VICTORIA L (MA, LLP, BCBA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 3 MILE RD NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8218
Mailing Address - Country:US
Mailing Address - Phone:616-647-3460
Mailing Address - Fax:616-647-3467
Practice Address - Street 1:680 3 MILE RD NW
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8218
Practice Address - Country:US
Practice Address - Phone:616-647-3460
Practice Address - Fax:616-647-3467
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-04-22
Deactivation Date:2007-02-13
Deactivation Code:
Reactivation Date:2008-02-26
Provider Licenses
StateLicense IDTaxonomies
MI6301012332103TB0200X
MI1-14-15288103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst