Provider Demographics
NPI:1750507190
Name:WILSON, MILDRED E
Entity Type:Individual
Prefix:MISS
First Name:MILDRED
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 STARGAZER ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7164
Mailing Address - Country:US
Mailing Address - Phone:951-217-1029
Mailing Address - Fax:951-358-4830
Practice Address - Street 1:6848 MAGNOLIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2858
Practice Address - Country:US
Practice Address - Phone:951-722-8990
Practice Address - Fax:951-358-4830
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health