Provider Demographics
NPI:1881690972
Name:WILSON, RICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 ANAHEIM ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3213
Mailing Address - Country:US
Mailing Address - Phone:310-534-5590
Mailing Address - Fax:310-534-5591
Practice Address - Street 1:1647 ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3213
Practice Address - Country:US
Practice Address - Phone:310-534-5590
Practice Address - Fax:310-534-5591
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8321103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8321OtherPSYCHOLOGIST
CACP8321,Medicare ID - Type UnspecifiedPSYCHOLOGIST