Healthcare Provider Details

I. General information

NPI: 1629257217
Provider Name (Legal Business Name): SELINA MARIE WILSON MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 21ST ST
BAKERSFIELD CA
93301-4709
US

IV. Provider business mailing address

9113 HOXIE CT
BAKERSFIELD CA
93311-1814
US

V. Phone/Fax

Practice location:
  • Phone: 661-861-9967
  • Fax:
Mailing address:
  • Phone: 661-565-4989
  • Fax: 661-664-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: