Provider Demographics
NPI:1598005787
Name:WILSON, LOREE ANN (MA/PPS/APCC)
Entity Type:Individual
Prefix:MRS
First Name:LOREE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA/PPS/APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 YULUPA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5213 EL MERCADO PKWY STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1301
Practice Address - Country:US
Practice Address - Phone:707-571-1714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA948101YM0800X
CA160255235101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health