Healthcare Provider Details

I. General information

NPI: 1679645089
Provider Name (Legal Business Name): AMBER WILSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 S HARLAN RD
LATHROP CA
95330-8738
US

IV. Provider business mailing address

PO BOX 577162
MODESTO CA
95357-7162
US

V. Phone/Fax

Practice location:
  • Phone: 209-647-7586
  • Fax:
Mailing address:
  • Phone: 209-647-7586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 53252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: