Provider Demographics
NPI:1396715058
Name:WILSON, PAUL G (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 CANYON DEL REY BLVD # 1047
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-3501
Mailing Address - Country:US
Mailing Address - Phone:505-563-0983
Mailing Address - Fax:
Practice Address - Street 1:1550 CANYON DEL REY BLVD # 1047
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-3501
Practice Address - Country:US
Practice Address - Phone:505-563-0983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical