Healthcare Provider Details

I. General information

NPI: 1326176934
Provider Name (Legal Business Name): LAURA BETH WILSON MSW; LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA BETH VILLA MSW; LCSW

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10221 COMPTON AVE SUITE 104
WATTS CA
90002-2802
US

IV. Provider business mailing address

10221 COMPTON AVE SUITE 104
WATTS CA
90002-2802
US

V. Phone/Fax

Practice location:
  • Phone: 310-783-4677
  • Fax:
Mailing address:
  • Phone: 310-783-4677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: