Provider Demographics
NPI:1649996695
Name:WILSON, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4057 EXCELSIOR RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-6116
Mailing Address - Country:US
Mailing Address - Phone:707-601-8218
Mailing Address - Fax:
Practice Address - Street 1:922 E ST STE 211
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1873
Practice Address - Country:US
Practice Address - Phone:707-957-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA857861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical