Provider Demographics
NPI:1962570259
Name:WILSON, DIANA LYNNE (MFT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 CARLOS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2005
Mailing Address - Country:US
Mailing Address - Phone:415-444-5580
Mailing Address - Fax:
Practice Address - Street 1:611 ARTHUR ST
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4499
Practice Address - Country:US
Practice Address - Phone:415-892-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42376106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist