Provider Demographics
NPI:1568781730
Name:WILSON, SHELLEY CAROL (MA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:CAROL
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 DOVE ST
Mailing Address - Street 2:SUITE 245
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2840
Mailing Address - Country:US
Mailing Address - Phone:949-922-7800
Mailing Address - Fax:951-600-2913
Practice Address - Street 1:1151 DOVE ST
Practice Address - Street 2:SUITE 245
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2840
Practice Address - Country:US
Practice Address - Phone:949-922-7800
Practice Address - Fax:951-600-2913
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT38154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist