Provider Demographics
NPI:1215483136
Name:WILSON, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 GRANT CT
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-1278
Mailing Address - Country:US
Mailing Address - Phone:810-358-1529
Mailing Address - Fax:
Practice Address - Street 1:5406 GATEWAY CTR
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3900
Practice Address - Country:US
Practice Address - Phone:810-358-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012081101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health