Provider Demographics
NPI:1861589574
Name:WILSON, T JOHN (LBSW)
Entity type:Individual
Prefix:MR
First Name:T
Middle Name:JOHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10343 OAK RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9768
Mailing Address - Country:US
Mailing Address - Phone:810-667-0500
Mailing Address - Fax:
Practice Address - Street 1:1570 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1154
Practice Address - Country:US
Practice Address - Phone:810-667-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801073733104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1705242 TYPE21Medicaid