Provider Demographics
NPI:1871848143
Name:WILSON, DEMETRA
Entity Type:Individual
Prefix:
First Name:DEMETRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 POTOMAC AVE APT 25
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1631
Mailing Address - Country:US
Mailing Address - Phone:323-815-1846
Mailing Address - Fax:
Practice Address - Street 1:3761 STOCKER ST STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5129
Practice Address - Country:US
Practice Address - Phone:323-294-4261
Practice Address - Fax:323-294-7261
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor