Provider Demographics
NPI:1952635096
Name:WILSON, MICHAEL W (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 MEMORIAL PKWY SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-4364
Mailing Address - Country:US
Mailing Address - Phone:256-533-1970
Mailing Address - Fax:256-705-6479
Practice Address - Street 1:4040 MEMORIAL PKWY SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-4364
Practice Address - Country:US
Practice Address - Phone:256-533-1970
Practice Address - Fax:256-705-6479
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1526103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling