Provider Demographics
NPI:1306625595
Name:GATLIN-WILSON, THELMA
Entity type:Individual
Prefix:MS
First Name:THELMA
Middle Name:
Last Name:GATLIN-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 1:2037 W BULLARD AVE # 372
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-1233
Mailing Address - Country:US
Mailing Address - Phone:559-978-2143
Mailing Address - Fax:559-412-8385
Practice Address - Street 1:5084 N FRUIT AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3000
Practice Address - Country:US
Practice Address - Phone:559-388-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC055800518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)