Provider Demographics
NPI:1043405525
Name:WILSON, BIANCA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:BIANCA
Middle Name:MICHELLE
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 1:3217 COHASSET RD
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-5404
Mailing Address - Country:US
Mailing Address - Phone:530-879-2456
Mailing Address - Fax:530-879-3932
Practice Address - Street 1:10 N SAN PEDRO RD STE 1020
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4155
Practice Address - Country:US
Practice Address - Phone:415-473-4306
Practice Address - Fax:415-473-4307
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59219106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-1063OtherFQHC MEDICARE PART A
CAZZZ29799ZOtherFQHC MEDICARE PART B