Provider Demographics
NPI:1568175982
Name:WILSON, TINA MARIE
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:HANCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 FULTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1646
Mailing Address - Country:US
Mailing Address - Phone:559-348-9225
Mailing Address - Fax:
Practice Address - Street 1:1401 FULTON ST STE 200
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1646
Practice Address - Country:US
Practice Address - Phone:559-348-9225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-30
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician