Healthcare Provider Details

I. General information

NPI: 1124763123
Provider Name (Legal Business Name): ERIKA ELYSE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E DEL MAR BLVD
PASADENA CA
91101-2714
US

IV. Provider business mailing address

250 S OAK KNOLL AVE APT 112
PASADENA CA
91101-4313
US

V. Phone/Fax

Practice location:
  • Phone: 626-664-9557
  • Fax:
Mailing address:
  • Phone: 626-664-9557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number5529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: