Provider Demographics
NPI:1790008340
Name:WILSON, REGINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:REGINE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 REDBUD WAY
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2157
Mailing Address - Country:US
Mailing Address - Phone:530-913-5129
Mailing Address - Fax:
Practice Address - Street 1:604 REDBUD WAY
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2157
Practice Address - Country:US
Practice Address - Phone:530-913-5129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS225801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical