Provider Demographics
NPI:1124542592
Name:WILSON, MARY DELORES (MFTI)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DELORES
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NA
Mailing Address - Street 1:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95696-0132
Mailing Address - Country:US
Mailing Address - Phone:707-301-6262
Mailing Address - Fax:
Practice Address - Street 1:2101 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6717
Practice Address - Country:US
Practice Address - Phone:707-784-2238
Practice Address - Fax:707-425-4038
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92709106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist