Provider Demographics
NPI:1952973737
Name:WILSON, DAVID (LLPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5844 DIX DR NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-9059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:781 KENMOOR AVE SE STE C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8624
Practice Address - Country:US
Practice Address - Phone:616-200-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401019214101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIW425135661744OtherDRIVER'S LICENSE