MEDICARE: DR. RICK WILSON PHD

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	103TC0700X	Clinical Psychologist	PSY8321	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY8321	OTHER	CA	PSYCHOLOGIST

General Provider Information

NPI Number	:	1881690972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICK WILSON PHD

Provider Business Mailing Address
First Line	:	1647 ANAHEIM ST
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-3213
Country	:	US
Telephone Number	:	310-534-5590
Fax Number	:	310-534-5591

Provider Business Practice Location Address
First Line	:	1647 ANAHEIM ST
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-3213
Country	:	US
Telephone Number	:	310-534-5590
Fax Number	:	310-534-5591

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	07/08/2007

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