Provider Demographics
NPI:1992032593
Name:WILSUSEN, MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:WILSUSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:PRIZEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2277 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3148
Mailing Address - Country:US
Mailing Address - Phone:516-377-5400
Mailing Address - Fax:
Practice Address - Street 1:2277 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3148
Practice Address - Country:US
Practice Address - Phone:516-377-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0780221041C0700X
NY076326104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01764850Medicaid