Provider Demographics
NPI:1821134271
Name:WILSON, TERRA RENNE (SAC II)
Entity Type:Individual
Prefix:MS
First Name:TERRA
Middle Name:RENNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:SAC II
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:RENNE
Other - Last Name:GOODRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RASI
Mailing Address - Street 1:9345 WINCHESTER
Mailing Address - Street 2:
Mailing Address - City:LOWER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95457-5720
Mailing Address - Country:US
Mailing Address - Phone:707-995-3235
Mailing Address - Fax:707-995-7004
Practice Address - Street 1:9345 WINCHESTER
Practice Address - Street 2:
Practice Address - City:LOWER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95457
Practice Address - Country:US
Practice Address - Phone:707-995-3235
Practice Address - Fax:707-995-7004
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CARI-G0505091545101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARI-G0505091545OtherSUBSTANCE ABUSE DISORDER