Healthcare Provider Details

I. General information

NPI: 1063883544
Provider Name (Legal Business Name): BLAINE WILSON LCSW, MED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

V. Phone/Fax

Practice location:
  • Phone: 916-843-6952
  • Fax:
Mailing address:
  • Phone: 916-843-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13231
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: