Basic Information
| Provider Information | |||||||||
| NPI: | 1760926208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | IMF84966 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 W HENDERSON AVE, STE #2 | ||||||||
| Address2: | |||||||||
| City: | PORTEVILLLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597190815 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 W HENDERSON AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932571490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597881200 | ||||||||
| FaxNumber: | 5597133717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2016 | ||||||||
| LastUpdateDate: | 12/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF84966 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.