Provider Demographics
NPI:1821749565
Name:WILSON, MICHAEL TYLER (ADT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TYLER
Last Name:WILSON
Suffix:
Gender:M
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 BLUE BALL AVE
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5222
Mailing Address - Country:US
Mailing Address - Phone:410-620-6077
Mailing Address - Fax:410-620-6081
Practice Address - Street 1:212 BLUE BALL AVE
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5222
Practice Address - Country:US
Practice Address - Phone:410-620-6077
Practice Address - Fax:410-620-6081
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)