Provider Demographics
NPI:1861685257
Name:WILSON, RANDALL GLENN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:GLENN
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7626 RADCLIFFE DR
Mailing Address - Street 2:APT. B
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2087
Mailing Address - Country:US
Mailing Address - Phone:732-232-0462
Mailing Address - Fax:
Practice Address - Street 1:3203 CLAIREMONT DR
Practice Address - Street 2:APT. 2
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6449
Practice Address - Country:US
Practice Address - Phone:732-232-0462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 8888103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical