Provider Demographics
NPI:1972665123
Name:WILSON, EARTHERN HERMAN II
Entity Type:Individual
Prefix:
First Name:EARTHERN
Middle Name:HERMAN
Last Name:WILSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 WATERMAN CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-2973
Mailing Address - Country:US
Mailing Address - Phone:707-479-5037
Mailing Address - Fax:
Practice Address - Street 1:740 BECK AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4440
Practice Address - Country:US
Practice Address - Phone:707-784-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker