Healthcare Provider Details

I. General information

NPI: 1861527913
Provider Name (Legal Business Name): ELISABETH MELLIE WILSON MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIS WILSON MFT

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N BROADWAY SUITE 2H
TURLOCK CA
95380-4811
US

IV. Provider business mailing address

125 N BROADWAY SUITE 2H
TURLOCK CA
95380-4811
US

V. Phone/Fax

Practice location:
  • Phone: 209-632-0565
  • Fax: 209-632-0530
Mailing address:
  • Phone: 209-632-0565
  • Fax: 209-632-0530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC42817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: