Provider Demographics
NPI:1841507316
Name:WILSON, JOHN DOUGLAS (MSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2816
Mailing Address - Country:US
Mailing Address - Phone:248-765-4512
Mailing Address - Fax:
Practice Address - Street 1:3611 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-2816
Practice Address - Country:US
Practice Address - Phone:248-765-4512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010160331041C0700X
IL149.0129031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical