Provider Demographics
NPI:1356968929
Name:WILSON, KEELE
Entity type:Individual
Prefix:
First Name:KEELE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 KNIGHTSBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-7115
Mailing Address - Country:US
Mailing Address - Phone:517-262-7716
Mailing Address - Fax:
Practice Address - Street 1:650 CHURCH ST STE 215
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1689
Practice Address - Country:US
Practice Address - Phone:833-222-4273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician