Healthcare Provider Details

I. General information

NPI: 1881823045
Provider Name (Legal Business Name): SAMANTHA DEWITT WILSON PSYD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10085 CARROLL CANYON RD STE 200H
SAN DIEGO CA
92131-1100
US

IV. Provider business mailing address

10085 CARROLL CANYON RD STE 200H
SAN DIEGO CA
92131-1100
US

V. Phone/Fax

Practice location:
  • Phone: 858-208-3463
  • Fax:
Mailing address:
  • Phone: 858-208-3463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY34430
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number34430
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number76389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: