Healthcare Provider Details

I. General information

NPI: 1902785884
Provider Name (Legal Business Name): BREANNA NICOLE WILSON MS, AMFT, APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/02/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1382 BLUE OAKS BLVD STE 213
ROSEVILLE CA
95678-7052
US

IV. Provider business mailing address

1382 BLUE OAKS BLVD STE 213
ROSEVILLE CA
95678-7052
US

V. Phone/Fax

Practice location:
  • Phone: 877-412-8031
  • Fax:
Mailing address:
  • Phone: 877-412-8031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22661
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number163437
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberF52B75186E
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: