Provider Demographics
NPI:1497051783
Name:WILSON, MELISSA BETH (MSC, LAC, DIPL)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:BETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSC, LAC, DIPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155A KENTUCKY STREET
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-280-5602
Mailing Address - Fax:
Practice Address - Street 1:155A KENTUCKY STREET
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-280-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5984171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist