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General NPI Number Information
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NPI Number | 1972665123
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Entity Type | Individual
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Provider Name | EARTHERN HERMAN WILSON II
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Gender | Male
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Dates
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Enumeration Date | 12/14/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 740 BECK AVE
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City | FAIRFIELD
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State | CA
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Zip | 94533-4440
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Country | US
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Telephone | 707-784-6570
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Fax |
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Provider Business Mailing Address
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Address Line | 2918 WATERMAN CT
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City | FAIRFIELD
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State | CA
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Zip | 94534-2973
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Country | US
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Telephone | 707-479-5037
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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