Provider Demographics
NPI:1083987549
Name:WILSON, ANITA LYNN (PHD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3245 UNIVERSITY AVE. 1-334
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5009
Mailing Address - Country:US
Mailing Address - Phone:619-281-6067
Mailing Address - Fax:619-795-0814
Practice Address - Street 1:4455 MURPHY CANYON RD
Practice Address - Street 2:100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4379
Practice Address - Country:US
Practice Address - Phone:619-281-6067
Practice Address - Fax:619-795-0814
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-00-0302103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst