Provider Demographics
NPI:1548794902
Name:WILSON, SHARON THOMPSON (LMFT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:THOMPSON
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 4TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4152
Mailing Address - Country:US
Mailing Address - Phone:530-304-3004
Mailing Address - Fax:
Practice Address - Street 1:509 4TH ST STE A
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4152
Practice Address - Country:US
Practice Address - Phone:530-304-3004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 19815106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC19815OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES