Healthcare Provider Details

I. General information

NPI: 1497951966
Provider Name (Legal Business Name): MS. NATASHA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 W. VICTORIA STREET
COMPTON CA
90220
US

IV. Provider business mailing address

2601 E VICTORIA ST SP 173
COMPTON CA
90220-6016
US

V. Phone/Fax

Practice location:
  • Phone: 310-868-5379
  • Fax: 310-868-5379
Mailing address:
  • Phone: 310-638-7915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: