Provider Demographics
NPI:1073913091
Name:WILSON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:KEITHLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 ATTU ROAD
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 ATTU RD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-6600
Practice Address - Country:US
Practice Address - Phone:731-697-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health