Healthcare Provider Details

I. General information

NPI: 1841737673
Provider Name (Legal Business Name): WAYNE R. WILSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DOC WILSON LCSW

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 08/08/2024
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 EAST TERRACE DR
ALTADENA CA
91101
US

IV. Provider business mailing address

736 BRIDGE ST UNIT 11
VERNONIA OR
97064-1285
US

V. Phone/Fax

Practice location:
  • Phone: 707-797-0064
  • Fax:
Mailing address:
  • Phone: 707-797-0064
  • Fax: 707-797-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW75482
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW91441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: