Provider Demographics
NPI:1962737569
Name:WILSON, MICHAEL S (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-251-5111
Practice Address - Street 1:7066 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-3937
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:651-251-5111
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical