Provider Demographics
NPI:1851596498
Name:WILSON, STEPHANIE DENISE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DENISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:415-600-5959
Mailing Address - Fax:415-369-1392
Practice Address - Street 1:601 DUBOCE AVE STE 250
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-3389
Practice Address - Country:US
Practice Address - Phone:415-600-5959
Practice Address - Fax:415-369-1392
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA965999103TF0200X, 2084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program