Provider Demographics
NPI:1285457150
Name:WILSON, RAKER ALAN (AMFT)
Entity type:Individual
Prefix:
First Name:RAKER
Middle Name:ALAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:VERDUGO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91046-0312
Mailing Address - Country:US
Mailing Address - Phone:406-207-3434
Mailing Address - Fax:
Practice Address - Street 1:16360 ROSCOE BLVD FL 2
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1219
Practice Address - Country:US
Practice Address - Phone:406-207-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT147918106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist