Healthcare Provider Details

I. General information

NPI: 1396715058
Provider Name (Legal Business Name): PAUL G. WILSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 CANYON DEL REY BLVD # 1047
SEASIDE CA
93955-3501
US

IV. Provider business mailing address

1550 CANYON DEL REY BLVD # 1047
SEASIDE CA
93955-3501
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-0983
  • Fax:
Mailing address:
  • Phone: 505-563-0983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: