Provider Demographics
NPI:1477033074
Name:TRIEU, WILSON
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:TRIEU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28767 FOX TAIL WAY
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-5709
Mailing Address - Country:US
Mailing Address - Phone:909-362-9097
Mailing Address - Fax:
Practice Address - Street 1:12125 DAY ST STE E301
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-6704
Practice Address - Country:US
Practice Address - Phone:951-344-2166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician