Provider Demographics
NPI:1417979634
Name:WILSON, SCOTT D (MFT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2955
Mailing Address - Country:US
Mailing Address - Phone:310-546-6500
Mailing Address - Fax:310-546-9068
Practice Address - Street 1:2007 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2955
Practice Address - Country:US
Practice Address - Phone:310-546-6500
Practice Address - Fax:310-546-9068
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25955106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist