Provider Demographics
NPI:1033496245
Name:WILSON, CLARENCE CARL (DBH, LPCC)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:CARL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DBH, LPCC
Other - Prefix:DR
Other - First Name:CARL
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DBH, LPCC, CADC
Mailing Address - Street 1:851 S MOUNT VERNON AVE STE 7A
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3926
Mailing Address - Country:US
Mailing Address - Phone:760-241-6044
Mailing Address - Fax:760-820-2704
Practice Address - Street 1:851 S MOUNT VERNON AVE STE 7A
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3926
Practice Address - Country:US
Practice Address - Phone:760-241-6044
Practice Address - Fax:760-820-2704
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARA8320316101YA0400X
IA074006101YM0800X
MO2011031159101YM0800X
CA2784101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional