Healthcare Provider Details

I. General information

NPI: 1235508367
Provider Name (Legal Business Name): RACHAEL ELIZABETH GARDINER WILSON JD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 SHATTUCK AVE
BERKELEY CA
94709-1768
US

IV. Provider business mailing address

1831 SOLANO AVE UNIT 7445
BERKELEY CA
94707-5023
US

V. Phone/Fax

Practice location:
  • Phone: 510-545-6508
  • Fax:
Mailing address:
  • Phone: 510-545-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number82817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: