Provider Demographics
NPI:1316584576
Name:WILSON, DOUG C (PSY 22708)
Entity Type:Individual
Prefix:DR
First Name:DOUG
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSY 22708
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 W RIVERSIDE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-5301
Mailing Address - Country:US
Mailing Address - Phone:323-791-6094
Mailing Address - Fax:
Practice Address - Street 1:3808 W RIVERSIDE DR STE 400
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-5301
Practice Address - Country:US
Practice Address - Phone:323-791-6094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical