Healthcare Provider Details

I. General information

NPI: 1780890723
Provider Name (Legal Business Name): INGRID MARIE WILSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 STOCKER ST #105
VIEW PARK CA
90008-5109
US

IV. Provider business mailing address

4712 ADMIRALTY WAY 512
MARINA DEL REY CA
90292-6905
US

V. Phone/Fax

Practice location:
  • Phone: 310-702-8460
  • Fax: 877-207-3820
Mailing address:
  • Phone: 310-702-8460
  • Fax: 877-207-3840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY15620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: