Provider Demographics
NPI:1629481346
Name:WILSON, O'BRIEN (MFTI)
Entity Type:Individual
Prefix:
First Name:O'BRIEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 E LASSEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-7823
Mailing Address - Country:US
Mailing Address - Phone:530-267-1766
Mailing Address - Fax:
Practice Address - Street 1:1360 E LASSEN AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-7823
Practice Address - Country:US
Practice Address - Phone:530-267-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79909390200000X
CA79909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program