Provider Demographics
NPI:1083110902
Name:WILSON, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
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 1:1910 OLYMPIC BLVD STE 140150
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5096
Mailing Address - Country:US
Mailing Address - Phone:925-433-0990
Mailing Address - Fax:
Practice Address - Street 1:14895 E 14TH ST STE 465
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2989
Practice Address - Country:US
Practice Address - Phone:510-346-7100
Practice Address - Fax:510-346-7101
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician