Healthcare Provider Details

I. General information

NPI: 1104210269
Provider Name (Legal Business Name): ELIZABETH WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 27TH ST
SAN DIEGO CA
92154-1444
US

IV. Provider business mailing address

1024 VISTA OAK PL
CHULA VISTA CA
91910-6793
US

V. Phone/Fax

Practice location:
  • Phone: 619-575-4687
  • Fax:
Mailing address:
  • Phone: 619-794-6937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: