Provider Demographics
NPI:1275763286
Name:WILSON, SAMUEL BERINGER (MSW)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:BERINGER
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-2109
Mailing Address - Country:US
Mailing Address - Phone:213-537-0822
Mailing Address - Fax:
Practice Address - Street 1:619 E 5TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-2109
Practice Address - Country:US
Practice Address - Phone:213-537-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW25311101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health