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General NPI Number Information
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NPI Number | 1023228442
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Entity Type | Individual
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Provider Name | MS. ELIZABETH KATHLEEN WILSON
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Gender | Female
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 04/01/2021
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Provider Practice Location Address
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Address Line | 6330 THORNTON AVE
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City | NEWARK
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State | CA
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Zip | 94560-3734
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Country | US
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Telephone | 510-792-4357
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Fax |
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Provider Business Mailing Address
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Address Line | 908 CRESTWOOD DR
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City | MODESTO
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State | CA
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Zip | 95350-1622
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Country | US
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Telephone | 510-943-7112
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | CA
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