Provider Demographics
NPI:1790819167
Name:WILSON, SHARON ELAINE (MA, MS, MFTI)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, MS, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12436 ALMENDRA WAY
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-7989
Mailing Address - Country:US
Mailing Address - Phone:760-947-0273
Mailing Address - Fax:
Practice Address - Street 1:762 W CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3505
Practice Address - Country:US
Practice Address - Phone:909-599-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health