Provider Demographics
NPI:1114549888
Name:WILSON, ANDREW TYLER
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:TYLER
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 RYAN LN
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-4002
Mailing Address - Country:US
Mailing Address - Phone:415-847-1534
Mailing Address - Fax:
Practice Address - Street 1:1260 N DUTTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-7121
Practice Address - Country:US
Practice Address - Phone:707-568-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT117515106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist