Provider Demographics
NPI:1396958013
Name:WILSON, DAVID LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
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 1:5200 CHURN CREEK RD STE E
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-3930
Mailing Address - Country:US
Mailing Address - Phone:530-223-2777
Mailing Address - Fax:530-223-0977
Practice Address - Street 1:5200 CHURN CREEK RD STE E
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-3930
Practice Address - Country:US
Practice Address - Phone:530-223-2777
Practice Address - Fax:530-223-0977
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 3325103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist