Provider Demographics
NPI:1285321463
Name:WILSON, WINIFRED
Entity type:Individual
Prefix:
First Name:WINIFRED
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E BELTLINE AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1267
Mailing Address - Country:US
Mailing Address - Phone:616-805-3660
Mailing Address - Fax:
Practice Address - Street 1:330 E BELTLINE AVE NE STE 320
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1267
Practice Address - Country:US
Practice Address - Phone:616-805-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health