Provider Demographics
NPI:1760926208
Name:WILSON, REBECCA T (IMF84966)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:T
Last Name:WILSON
Suffix:
Gender:F
Credentials:IMF84966
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 W HENDERSON AVE, STE #2
Mailing Address - Street 2:
Mailing Address - City:PORTEVILLLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257
Mailing Address - Country:US
Mailing Address - Phone:559-719-0815
Mailing Address - Fax:
Practice Address - Street 1:1055 W HENDERSON AVE STE 2
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1490
Practice Address - Country:US
Practice Address - Phone:559-788-1200
Practice Address - Fax:559-713-3717
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF84966106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist