Provider Demographics
NPI:1710478524
Name:WILKINSON, MARISSA S
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:S
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6580 BALSAM DR APT 201
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9233
Mailing Address - Country:US
Mailing Address - Phone:517-617-9066
Mailing Address - Fax:
Practice Address - Street 1:1000 E PARIS AVE SE STE 160
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8313
Practice Address - Country:US
Practice Address - Phone:616-608-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician