Provider Demographics
NPI:1124770664
Name:WILSON, TONI (LMSW-CLINICAL)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW-CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 WOODWARD AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4426
Mailing Address - Country:US
Mailing Address - Phone:833-460-5551
Mailing Address - Fax:
Practice Address - Street 1:1025 WOODWARD AVE APT 310
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4426
Practice Address - Country:US
Practice Address - Phone:833-460-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011136471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical