Provider Demographics
NPI:1831294297
Name:WILSON, GLENN DAVID (MS,CAC1,ADOA)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS,CAC1,ADOA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 SARATOGA DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2650
Mailing Address - Country:US
Mailing Address - Phone:248-343-1368
Mailing Address - Fax:
Practice Address - Street 1:1435 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1549
Practice Address - Country:US
Practice Address - Phone:248-406-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)