Provider Demographics
NPI:1851918627
Name:WILSON, JUANITA (AMFT)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18350 MOUNT LANGLEY ST STE 220
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6912
Mailing Address - Country:US
Mailing Address - Phone:714-450-4118
Mailing Address - Fax:
Practice Address - Street 1:2275 S MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5303
Practice Address - Country:US
Practice Address - Phone:951-279-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-28
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty