Provider Demographics
NPI:1386161040
Name:WILSON, MARY JANE (BSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 BASAL RD
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:241 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-1955
Practice Address - Country:US
Practice Address - Phone:906-228-7611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)