Provider Demographics
NPI:1669557641
Name:WILSON, MICKEY (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:HELENEMICKEY
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4000 MACARTHUR BLVD., EAST TOWER, 6TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2543
Mailing Address - Country:US
Mailing Address - Phone:714-743-5612
Mailing Address - Fax:
Practice Address - Street 1:4000 MACARTHUR BLVD., EAST TOWER, 6TH FLOOR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2543
Practice Address - Country:US
Practice Address - Phone:714-743-5612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101Y00000X
CA49203106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49203OtherLICENSE