Provider Demographics
NPI:1164966073
Name:WILSON, LAURA (LMFT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:BUCKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:540 N GOLDEN CIRCLE DR STE 312
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3926
Mailing Address - Country:US
Mailing Address - Phone:415-503-7529
Mailing Address - Fax:
Practice Address - Street 1:3555 WHIPPLE RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-675-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105121106H00000X, 106H00000X
CA91954106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist