Provider Demographics
NPI:1972155406
Name:WILSON, INGRID CHARLOTTE
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:CHARLOTTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10882 MACOUBA PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2043
Mailing Address - Country:US
Mailing Address - Phone:619-964-4325
Mailing Address - Fax:858-569-8626
Practice Address - Street 1:5210 BALBOA AVE STE F
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6958
Practice Address - Country:US
Practice Address - Phone:619-239-5433
Practice Address - Fax:619-546-5422
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28480225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist