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General NPI Number Information
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NPI Number | 1881823045
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Entity Type | Individual
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Provider Name | SAMANTHA DEWITT WILSON PSYD, LCSW
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Gender | Female
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Dates
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Enumeration Date | 07/09/2009
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 10085 CARROLL CANYON RD STE 200H
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City | SAN DIEGO
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State | CA
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Zip | 92131-1100
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Country | US
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Telephone | 858-208-3463
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Fax |
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Provider Business Mailing Address
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Address Line | 10085 CARROLL CANYON RD STE 200H
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City | SAN DIEGO
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State | CA
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Zip | 92131-1100
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Country | US
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Telephone | 858-208-3463
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 34430
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 76389
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PSY34430
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License Number State | CA
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