=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811225873
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QUINCY L. WILKINS MFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2009
-----------------------------------------------------
Last Update Date | 01/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6355 TELEGRAPH AVE STE 308
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-610-2026
-----------------------------------------------------
Fax | 510-619-7222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8763
-----------------------------------------------------
City | EMERYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94662-0763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-610-2026
-----------------------------------------------------
Fax | 510-619-7222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 45564
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------