Provider Demographics
NPI:1861527913
Name:WILSON, ELISABETH MELLIE (MFT)
Entity type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:MELLIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MRS
Other - First Name:LIS
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:125 N BROADWAY
Mailing Address - Street 2:SUITE 2H
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-4811
Mailing Address - Country:US
Mailing Address - Phone:209-632-0565
Mailing Address - Fax:209-632-0530
Practice Address - Street 1:125 N BROADWAY
Practice Address - Street 2:SUITE 2H
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-4811
Practice Address - Country:US
Practice Address - Phone:209-632-0565
Practice Address - Fax:209-632-0530
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42817106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist