Provider Demographics
NPI:1205998077
Name:WILSON, KAREN THERESE (LCSW)
Entity type:Individual
Prefix:MISS
First Name:KAREN
Middle Name:THERESE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 927321
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92192-7321
Mailing Address - Country:US
Mailing Address - Phone:619-615-8944
Mailing Address - Fax:858-452-2012
Practice Address - Street 1:8950 VILLA LA JOLLA DR
Practice Address - Street 2:SUITE 204B
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:619-615-8944
Practice Address - Fax:858-452-2012
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS171321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LCSI7132DMedicare ID - Type Unspecified