Provider Demographics
NPI:1902935042
Name:WILSON, PATRICIA ANN (MA)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SYCAMORE DR STE 8
Mailing Address - Street 2:(MAIL) P. O. BOX 1594
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-2942
Mailing Address - Country:US
Mailing Address - Phone:925-759-0649
Mailing Address - Fax:
Practice Address - Street 1:2400 SYCAMORE DR
Practice Address - Street 2:SUITE 8
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2910
Practice Address - Country:US
Practice Address - Phone:925-759-0649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45629106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist