Provider Demographics
NPI:1588952204
Name:WILSON, BRIAN A (MA, LMFT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91017-0153
Mailing Address - Country:US
Mailing Address - Phone:818-524-9282
Mailing Address - Fax:
Practice Address - Street 1:507 W FOOTHILL BLVD # B
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2021
Practice Address - Country:US
Practice Address - Phone:626-427-7357
Practice Address - Fax:818-243-5431
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93754106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist