1205998077 NPI number — MISS KAREN THERESE WILSON LCSW

Table of content: MISS KAREN THERESE WILSON LCSW (NPI 1205998077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205998077 NPI number — MISS KAREN THERESE WILSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
KAREN
Provider Middle Name:
THERESE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205998077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 927321
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92192-7321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-615-8944
Provider Business Mailing Address Fax Number:
858-452-2012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8950 VILLA LA JOLLA DR
Provider Second Line Business Practice Location Address:
SUITE 204B
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-615-8944
Provider Business Practice Location Address Fax Number:
858-452-2012
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS17132 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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