Provider Demographics
NPI:1316011489
Name:WILSON, BETH (EDD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 HYDE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-1505
Mailing Address - Country:US
Mailing Address - Phone:415-441-0773
Mailing Address - Fax:
Practice Address - Street 1:901 NEVIN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3143
Practice Address - Country:US
Practice Address - Phone:510-307-2476
Practice Address - Fax:510-307-1808
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13101103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist