MEDICARE: CORY WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1073630448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY WILSON

Provider Business Mailing Address
First Line	:	41009 CHAMBORD DR
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92532-1533
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2275 S MAIN ST STE 201
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92882-5303
Country	:	US
Telephone Number	:	951-279-1333
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	09/27/2023

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Directions to “ CORY WILSON ” Practice Location

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