Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | ||
Y | 225400000X | Rehabilitation Practitioner | CA |
NPI | 1013453695 |
---|---|
Provider Name | Ms. Michele R Wilson |
First Address | Los Angeles, CA 90004-2306 |
Second Address | Los Angeles, CA 90004-2306 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/01/2017 |
Last Update Date | 14/04/2017 |