Provider Demographics
NPI:1073721007
Name:WILSON, DAN A (LCSW)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 CLAREMONT AVE STE 216
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5700
Mailing Address - Country:US
Mailing Address - Phone:209-472-3763
Mailing Address - Fax:209-472-3751
Practice Address - Street 1:5250 CLAREMONT AVE STE 216
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5700
Practice Address - Country:US
Practice Address - Phone:209-472-3763
Practice Address - Fax:209-472-3751
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS153331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical