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General NPI Number Information
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NPI Number | 1144973553
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Entity Type | Individual
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Provider Name | STEVEN WILSON
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Gender | Male
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Dates
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Enumeration Date | 01/27/2022
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Last Update Date | 03/08/2022
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Provider Practice Location Address
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Address Line | 109 N AVENUE 56 STE B
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City | LOS ANGELES
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State | CA
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Zip | 90042-4111
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Country | US
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Telephone | 213-793-8223
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 50591
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City | LOS ANGELES
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State | CA
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Zip | 90050-0591
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Country | US
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Telephone |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 11074
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 130789
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License Number State | CA
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