MEDICARE: MRS. BRIDGET BROWN WILSON M.S.W

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	16773	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16773	OTHER	CA	ASW REGISTRATION NUMBER

General Provider Information

NPI Number	:	1669696324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRIDGET BROWN WILSON M.S.W

Provider Business Mailing Address
First Line	:	4543 LONGHORN ST
Second Line	:
City	:	CARMICHAEL
State	:	CA
Zip	:	95608-1229
Country	:	US
Telephone Number	:	916-482-8983
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 AUBURN BLVD
Second Line	:	SUITE A
City	:	SACRAMENTO
State	:	CA
Zip	:	95821-1831
Country	:	US
Telephone Number	:	916-483-2154
Fax Number	:	916-483-2850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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