Provider Demographics
NPI:1891902078
Name:WILSON, CHERYL
Entity Type:Individual
Prefix:
First Name:CHERYL
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 1:3280 OLIVE ST
Mailing Address - Street 2:28
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-1767
Mailing Address - Country:US
Mailing Address - Phone:619-465-0733
Mailing Address - Fax:
Practice Address - Street 1:3280 OLIVE ST
Practice Address - Street 2:28
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1767
Practice Address - Country:US
Practice Address - Phone:619-465-0733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)