Provider Demographics
NPI:1871244244
Name:WILSON, BRADLEY THOMAS (LMFT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:THOMAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18430 BROOKHURST ST STE 202A
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6758
Mailing Address - Country:US
Mailing Address - Phone:714-253-4537
Mailing Address - Fax:
Practice Address - Street 1:18430 BROOKHURST ST STE 202A
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6758
Practice Address - Country:US
Practice Address - Phone:714-253-4537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130605261QM0850X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health