Healthcare Provider Details

I. General information

NPI: 1790819167
Provider Name (Legal Business Name): SHARON ELAINE WILSON M.A., M.S., MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 W CYPRESS AVE
SAN DIMAS CA
91773-3505
US

IV. Provider business mailing address

12436 ALMENDRA WAY
VICTORVILLE CA
92392-7989
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-1227
  • Fax:
Mailing address:
  • Phone: 760-947-0273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: