Healthcare Provider Details

I. General information

NPI: 1194209486
Provider Name (Legal Business Name): CANDY JANE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 AUBURN BLVD
SACRAMENTO CA
95841-4139
US

IV. Provider business mailing address

8912 VOLUNTEER LN
SACRAMENTO CA
95826-3221
US

V. Phone/Fax

Practice location:
  • Phone: 916-473-5764
  • Fax:
Mailing address:
  • Phone: 916-344-0199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-UJSXAN
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: