Healthcare Provider Details

I. General information

NPI: 1437065703
Provider Name (Legal Business Name): PRENTICE DEONARD WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2648 DEL PASO BLVD
SACRAMENTO CA
95815-2352
US

IV. Provider business mailing address

PO BOX 340511
SACRAMENTO CA
95834-0511
US

V. Phone/Fax

Practice location:
  • Phone: 916-821-3423
  • Fax:
Mailing address:
  • Phone: 916-821-3423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: