Provider Demographics
NPI:1619011723
Name:HARRIS-WILSON, DIANE J (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:J
Last Name:HARRIS-WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 17TH STREET
Mailing Address - Street 2:SUITE 530
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1503
Mailing Address - Country:US
Mailing Address - Phone:510-452-4281
Mailing Address - Fax:510-452-4281
Practice Address - Street 1:519 17TH ST
Practice Address - Street 2:SUITE 530
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1527
Practice Address - Country:US
Practice Address - Phone:510-452-4281
Practice Address - Fax:510-452-4281
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9780103T00000X
MA2990103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL97800Medicare ID - Type UnspecifiedPROVIDER ID