Provider Demographics
NPI:1023745999
Name:WILSON, TAMMARA S (LLPC, MSW)
Entity type:Individual
Prefix:
First Name:TAMMARA
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:LLPC, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 MARKUS GLEN DR
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9557
Mailing Address - Country:US
Mailing Address - Phone:269-598-3776
Mailing Address - Fax:
Practice Address - Street 1:319 PARK ST
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1655
Practice Address - Country:US
Practice Address - Phone:269-685-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health