Provider Demographics
NPI:1639494354
Name:WILSON, CRAIG KYLE (RS)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:KYLE
Last Name:WILSON
Suffix:
Gender:M
Credentials:RS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 KEMPER ST.
Mailing Address - Street 2:STE.105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3107
Mailing Address - Country:US
Mailing Address - Phone:619-807-3170
Mailing Address - Fax:
Practice Address - Street 1:3340 KEMPER ST.
Practice Address - Street 2:STE.105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3107
Practice Address - Country:US
Practice Address - Phone:619-807-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA373781Medicaid