Provider Demographics
NPI:1821340373
Name:WILSON, RONALD VIRGIL JR
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:VIRGIL
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 OCEAN AVENUE
Mailing Address - Street 2:APT. A
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-6446
Mailing Address - Country:US
Mailing Address - Phone:832-229-7737
Mailing Address - Fax:
Practice Address - Street 1:1200 N MAIN ST
Practice Address - Street 2:ROOM 325
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3640
Practice Address - Country:US
Practice Address - Phone:714-480-6357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 67548106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist