Provider Demographics
NPI:1265979355
Name:WILSON, TAMMY SUE (LPC)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI6401017239101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty