Healthcare Provider Details

I. General information

NPI: 1912569609
Provider Name (Legal Business Name): SANDRA LYNN WILSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 N MAIN ST STE 130
SANTA ANA CA
92705-6665
US

IV. Provider business mailing address

PO BOX 442
PLACENTIA CA
92871-0442
US

V. Phone/Fax

Practice location:
  • Phone: 714-274-7577
  • Fax:
Mailing address:
  • Phone: 562-237-8879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112689
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number131566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: