Provider Demographics
NPI:1013453695
Name:WILSON, MICHELE R
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:R
Last Name:WILSON
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 1:433 N HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-2306
Mailing Address - Country:US
Mailing Address - Phone:323-644-2040
Mailing Address - Fax:323-644-2036
Practice Address - Street 1:433 N HOOVER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-2306
Practice Address - Country:US
Practice Address - Phone:323-644-2040
Practice Address - Fax:323-644-2036
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health