Healthcare Provider Details

I. General information

NPI: 1891653010
Provider Name (Legal Business Name): BLAKE WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 18TH ST STE 350
SAN FRANCISCO CA
94110-2077
US

IV. Provider business mailing address

3150 18TH ST STE 350
SAN FRANCISCO CA
94110-2077
US

V. Phone/Fax

Practice location:
  • Phone: 510-619-2597
  • Fax:
Mailing address:
  • Phone: 510-619-2597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: