Provider Demographics
NPI:1952774739
Name:WILSON, COURTNEY (MSTOM RAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSTOM RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 EASTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2606
Mailing Address - Country:US
Mailing Address - Phone:989-341-1070
Mailing Address - Fax:888-965-5108
Practice Address - Street 1:4710 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2606
Practice Address - Country:US
Practice Address - Phone:989-341-1070
Practice Address - Fax:888-965-5108
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5401000052171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist