1174255830 NPI number — TAMMY SUE WILSON

Table of content: (NPI 1174255830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174255830 NPI number — TAMMY SUE WILSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAMMY SUE WILSON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RESILIENCE COUNSELING & PLAY THERAPY, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174255830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3115 LAPEER RD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060-7309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-637-1183
Provider Business Mailing Address Fax Number:
810-637-1183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3115 LAPEER RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-7309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-637-1183
Provider Business Practice Location Address Fax Number:
810-637-1183
Provider Enumeration Date:
06/29/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
810-637-1183

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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