Provider Demographics
NPI:1194938365
Name:WILSON, CONSTANCE BERTHEA
Entity type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:BERTHEA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1877 MANZANA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-4041
Mailing Address - Country:US
Mailing Address - Phone:619-470-0108
Mailing Address - Fax:619-470-3440
Practice Address - Street 1:1840 WILSON AVE
Practice Address - Street 2:C
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-5515
Practice Address - Country:US
Practice Address - Phone:619-477-0757
Practice Address - Fax:619-477-0799
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker