Healthcare Provider Details

I. General information

NPI: 1760204044
Provider Name (Legal Business Name): SARAH MICHELLE WILSON PPS SCHOOL PSYCHOLOG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. SARAH MICHELLE DANIELS

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SCHOOL ROAD
MIRANDA CA
95553
US

IV. Provider business mailing address

110 SCHOOL ROAD P.O. BOX 650
MIRANDA CA
95553
US

V. Phone/Fax

Practice location:
  • Phone: 707-943-1789
  • Fax: 707-943-1921
Mailing address:
  • Phone: 707-943-1789
  • Fax: 707-943-1921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number240125724PPS
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: