Provider Demographics
NPI:1265034367
Name:MONTECINOS-WILSON, CORAL
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:
Last Name:MONTECINOS-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 1:3490 LA SIERRA AVE STE F920
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5214
Mailing Address - Country:US
Mailing Address - Phone:951-723-5311
Mailing Address - Fax:
Practice Address - Street 1:3490 LA SIERRA AVE STE F920
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5214
Practice Address - Country:US
Practice Address - Phone:951-723-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170198472103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty