Provider Demographics
NPI:1588159370
Name:WILSON, MELINDA (PSYD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 OLD RANCH DR
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-1024
Mailing Address - Country:US
Mailing Address - Phone:805-245-9619
Mailing Address - Fax:
Practice Address - Street 1:11163 LA QUINTA PL STE B100
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5258
Practice Address - Country:US
Practice Address - Phone:915-201-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39314103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program