Provider Demographics
NPI:1386749240
Name:WILSON, JOYCE (PSYCHOLOGIST)
Entity type:Individual
Prefix:MS
First Name:JOYCE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677A EAST MAIN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032
Mailing Address - Country:US
Mailing Address - Phone:269-467-1000
Mailing Address - Fax:269-467-3075
Practice Address - Street 1:677A EAST MAIN
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:269-467-3075
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009453101YM0800X
MI6301007523103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid