Provider Demographics
NPI:1245470012
Name:WILSON, KAREN I (PHD)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:I
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:I
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:11340 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE-250
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1608
Mailing Address - Country:US
Mailing Address - Phone:310-876-4294
Mailing Address - Fax:310-943-2690
Practice Address - Street 1:11340 W OLYMPIC BLVD.
Practice Address - Street 2:SUITE-250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-876-4294
Practice Address - Fax:310-943-2690
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18249103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist