Provider Demographics
NPI:1205249430
Name:WILSON, GREGORY ALVIN SR (LMSW)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALVIN
Last Name:WILSON
Suffix:SR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MEDGAR EVERS ST
Mailing Address - Street 2:
Mailing Address - City:GRAMBLING
Mailing Address - State:LA
Mailing Address - Zip Code:71245-3211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG ROAD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037
Practice Address - Country:US
Practice Address - Phone:269-223-6907
Practice Address - Fax:269-223-6907
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9259171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider