Provider Demographics
NPI:1366008799
Name:WILSON, JULIE RAE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:RAE
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 1:109 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-2157
Mailing Address - Country:US
Mailing Address - Phone:951-427-3482
Mailing Address - Fax:
Practice Address - Street 1:109 E 11TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-2157
Practice Address - Country:US
Practice Address - Phone:951-427-3482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6371101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)