Provider Demographics
NPI:1285335885
Name:WILSON, MARY (MT-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 JESSAEL DR
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:MI
Mailing Address - Zip Code:48808-9791
Mailing Address - Country:US
Mailing Address - Phone:517-745-4992
Mailing Address - Fax:
Practice Address - Street 1:4930 S HAGADORN RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5312
Practice Address - Country:US
Practice Address - Phone:517-355-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist