Healthcare Provider Details

I. General information

NPI: 1952452823
Provider Name (Legal Business Name): LESLIE ANN WILSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6134 E. HIGHWAY 20
LUCERNE CA
95458
US

IV. Provider business mailing address

PO BOX 460
GLENHAVEN CA
95443-0460
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-9822
  • Fax: 707-274-9822
Mailing address:
  • Phone: 707-274-9822
  • Fax: 707-274-9822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number38813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: