Provider Demographics
NPI:1356190185
Name:WILSON, MICHAEL
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6914 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-2734
Mailing Address - Country:US
Mailing Address - Phone:314-240-0208
Mailing Address - Fax:708-778-7917
Practice Address - Street 1:914 N 2ND ST APT 8
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2070
Practice Address - Country:US
Practice Address - Phone:314-240-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral