Healthcare Provider Details

I. General information

NPI: 1649019290
Provider Name (Legal Business Name): WILPSYCH PROF. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 GRAND SUMMIT DR APT 142
RENO NV
89523-2558
US

IV. Provider business mailing address

1350 GRAND SUMMIT DR APT 142
RENO NV
89523-2558
US

V. Phone/Fax

Practice location:
  • Phone: 775-561-0442
  • Fax: 775-996-5208
Mailing address:
  • Phone: 775-561-0442
  • Fax: 775-996-5208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. MARQUEZ ERVIN WILSON
Title or Position: OWNER
Credential: PSYD
Phone: 775-561-0442