Provider Demographics
NPI:1063919769
Name:WILSON, CORAL LYNN (RADT)
Entity type:Individual
Prefix:MISS
First Name:CORAL
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 FIELDING CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-4420
Mailing Address - Country:US
Mailing Address - Phone:916-256-9801
Mailing Address - Fax:
Practice Address - Street 1:4049 MILLER WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1332
Practice Address - Country:US
Practice Address - Phone:916-451-9312
Practice Address - Fax:916-451-9312
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
C340020OtherGATEWAY