Provider Demographics
NPI:1245848365
Name:WILSON, MARIA ANNE (MALMFT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MALMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 2ND ST APT F110
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1513
Mailing Address - Country:US
Mailing Address - Phone:510-301-4542
Mailing Address - Fax:
Practice Address - Street 1:2339 11TH ST
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6604
Practice Address - Country:US
Practice Address - Phone:760-456-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115205106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty