Provider Demographics
NPI:1285988840
Name:WILSON, MISTY D (LMFT)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 BANTRY WAY
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3804
Mailing Address - Country:US
Mailing Address - Phone:707-373-6260
Mailing Address - Fax:
Practice Address - Street 1:816 BANTRY WAY
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-3804
Practice Address - Country:US
Practice Address - Phone:707-373-6260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43122106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist