Provider Demographics
NPI:1619291390
Name:WILSON, RUDOLPH
Entity Type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:
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 1:982 MISSION
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-5144
Mailing Address - Country:US
Mailing Address - Phone:415-861-0828
Mailing Address - Fax:415-861-0257
Practice Address - Street 1:982 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2911
Practice Address - Country:US
Practice Address - Phone:415-489-7306
Practice Address - Fax:415-861-0257
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator