Provider Demographics
NPI:1205274263
Name:WILSON, STEFANI RUTH (MFT)
Entity type:Individual
Prefix:
First Name:STEFANI
Middle Name:RUTH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 COTTAGE WAY
Mailing Address - Street 2:SUITE # 6
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1232
Mailing Address - Country:US
Mailing Address - Phone:916-595-3974
Mailing Address - Fax:
Practice Address - Street 1:2717 COTTAGE WAY
Practice Address - Street 2:SUITE # 6
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-1232
Practice Address - Country:US
Practice Address - Phone:916-595-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MFC40574106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist