Healthcare Provider Details

I. General information

NPI: 1821134271
Provider Name (Legal Business Name): TERRA RENNE WILSON SAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TERRA RENNE GOODRICH RASI

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9345 WINCHESTER
LOWER LAKE CA
95457
US

IV. Provider business mailing address

9345 WINCHESTER
LOWER LAKE CA
95457-5720
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-3235
  • Fax: 707-995-7004
Mailing address:
  • Phone: 707-995-3235
  • Fax: 707-995-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRI-G0505091545
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: