Healthcare Provider Details

I. General information

NPI: 1821260480
Provider Name (Legal Business Name): ROBIN WILSON LCSW #73335
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 ENBORG CT UNIT 100
SAN JOSE CA
95128-2645
US

IV. Provider business mailing address

871 ENBORG CT UNIT 100
SAN JOSE CA
95128-2645
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-6482
  • Fax: 408-885-5376
Mailing address:
  • Phone: 408-793-2425
  • Fax: 408-448-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number# NA201302
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW #23491
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: