Provider Demographics
NPI:1194105510
Name:WILSON, MOLLY ROSE (PHD, LLPC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, LLPC
Other - Prefix:DR
Other - First Name:MOLLY
Other - Middle Name:ROSE
Other - Last Name:DINKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7195 THORNAPPLE RIVER DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8411
Mailing Address - Country:US
Mailing Address - Phone:616-929-0248
Mailing Address - Fax:
Practice Address - Street 1:7195 THORNAPPLE RIVER DR SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8411
Practice Address - Country:US
Practice Address - Phone:616-929-0248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-822101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health