Provider Demographics
NPI:1538463138
Name:WILSON, ALLEN C JR
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:C
Last Name:WILSON
Suffix:JR
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 1:1231 BANCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1850
Mailing Address - Country:US
Mailing Address - Phone:510-540-7161
Mailing Address - Fax:
Practice Address - Street 1:4505 TAFT AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-3449
Practice Address - Country:US
Practice Address - Phone:510-235-3172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health