Provider Demographics
NPI:1962629071
Name:WILSON, ERICA G (PHD)
Entity type:Individual
Prefix:DR
First Name:ERICA
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N BARRANCA AVE # 3912
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1722
Mailing Address - Country:US
Mailing Address - Phone:951-223-5593
Mailing Address - Fax:
Practice Address - Street 1:23786 WATERLEAF CIR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-2914
Practice Address - Country:US
Practice Address - Phone:818-687-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17661103G00000X, 103TC0700X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP17661Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST