Healthcare Provider Details

I. General information

NPI: 1598005787
Provider Name (Legal Business Name): LOREE ANN WILSON M.A./PPS/APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5213 EL MERCADO PKWY STE A
SANTA ROSA CA
95403-1301
US

IV. Provider business mailing address

1000 YULUPA AVE
SANTA ROSA CA
95405-7020
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-1714
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number948
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number160255235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: