Provider Demographics
NPI:1275524753
Name:WILSON, CLAIRE (PHD)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4166
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92605-4166
Mailing Address - Country:US
Mailing Address - Phone:714-899-4005
Mailing Address - Fax:714-899-4275
Practice Address - Street 1:16480 HARBOR BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1361
Practice Address - Country:US
Practice Address - Phone:714-899-4005
Practice Address - Fax:714-899-4275
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12485101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12485AMedicare ID - Type Unspecified