Provider Demographics
NPI:1225648090
Name:WILSON, ARIEL
Entity Type:Individual
Prefix:
First Name:ARIEL
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 1:515 COLUMBIA AVE # 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1209
Mailing Address - Country:US
Mailing Address - Phone:213-249-9388
Mailing Address - Fax:213-389-7993
Practice Address - Street 1:515 COLUMBIA AVE # 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1209
Practice Address - Country:US
Practice Address - Phone:213-249-9388
Practice Address - Fax:213-389-7993
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA96107101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator