Provider Demographics
NPI:1538451463
Name:WILSON, MALIK (MASTERS DEGREE)
Entity type:Individual
Prefix:MR
First Name:MALIK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MASTERS DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-5381
Mailing Address - Country:US
Mailing Address - Phone:413-539-2978
Mailing Address - Fax:
Practice Address - Street 1:1233 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5381
Practice Address - Country:US
Practice Address - Phone:413-539-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X101YM0800X
MA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health