Provider Demographics
NPI:1174255830
Name:TAMMY SUE WILSON
Entity type:Organization
Organization Name:TAMMY SUE WILSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC, RPT, ICST
Authorized Official - Phone:810-637-1183
Mailing Address - Street 1:3115 LAPEER RD STE A
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7309
Mailing Address - Country:US
Mailing Address - Phone:810-637-1183
Mailing Address - Fax:810-637-1183
Practice Address - Street 1:3115 LAPEER RD STE A
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-7309
Practice Address - Country:US
Practice Address - Phone:810-637-1183
Practice Address - Fax:810-637-1183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-29
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty