MEDICARE: NANCY WILSON CADC-II

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	A018330415	CA

General Provider Information

NPI Number	:	1851858575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY WILSON CADC-II

Provider Business Mailing Address
First Line	:	2001 HARBOR BLVD STE 200
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-8518
Country	:	US
Telephone Number	:	888-418-4188
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 HARBOR BLVD STE 200
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-8518
Country	:	US
Telephone Number	:	888-418-4188
Fax Number	:	949-209-0369

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

Provider Enumeration Date	:	02/28/2019
Last Update Date	:	02/28/2019

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