Provider Demographics
NPI:1306376629
Name:WILSON, SCOTT WILLIAM
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 N GAFFEY ST STE 219&221
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-1267
Mailing Address - Country:US
Mailing Address - Phone:424-570-0241
Mailing Address - Fax:
Practice Address - Street 1:1891 N. GAFFEY STREET SUITE 219 & 221
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90036
Practice Address - Country:US
Practice Address - Phone:424-570-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator