Provider Demographics
NPI:1578298279
Name:WILSON, CARLEON CHRISTOS
Entity Type:Individual
Prefix:
First Name:CARLEON
Middle Name:CHRISTOS
Last Name:WILSON
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 1:851 S MOUNT VERNON AVE STE 7A
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3926
Mailing Address - Country:US
Mailing Address - Phone:760-241-6044
Mailing Address - Fax:909-639-7079
Practice Address - Street 1:851 S MOUNT VERNON AVE STE 7A
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3926
Practice Address - Country:US
Practice Address - Phone:760-241-6044
Practice Address - Fax:909-639-7079
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist