Provider Demographics
NPI:1295200665
Name:WILSON, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
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:PO BOX 7026
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-0026
Mailing Address - Country:US
Mailing Address - Phone:510-295-9632
Mailing Address - Fax:510-269-9031
Practice Address - Street 1:3301 E 12TH ST STE 259
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2940
Practice Address - Country:US
Practice Address - Phone:510-295-9632
Practice Address - Fax:510-269-9031
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106533106H00000X
CARBT-18-54640106S00000X
CA390200000X
CA139885106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program