Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003151457 |
---|---|
Provider Name | Michele Wilson |
First Address | Johnston, RI 02919-3223 |
Second Address | Johnston, RI 02919-3223 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2012 |
Last Update Date | 11/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
GH57134 | (05) | RI |