Provider Demographics
NPI:1720120256
Name:FLANDERS, WILSON BEZERRA (MA, LPCC, LMHC)
Entity Type:Individual
Prefix:MR
First Name:WILSON
Middle Name:BEZERRA
Last Name:FLANDERS
Suffix:
Gender:M
Credentials:MA, LPCC, LMHC
Other - Prefix:MR
Other - First Name:WILSON
Other - Middle Name:
Other - Last Name:BEZERRA-FLANDERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPCC, LMHC
Mailing Address - Street 1:751 EBLITHEDALE AVE. # 643
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94942-0643
Mailing Address - Country:US
Mailing Address - Phone:415-647-9839
Mailing Address - Fax:415-390-1245
Practice Address - Street 1:751 EBLITHEDALE AVE.
Practice Address - Street 2:# 643
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94942-0643
Practice Address - Country:US
Practice Address - Phone:415-647-9839
Practice Address - Fax:415-390-1245
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 8586101YM0800X
NY3092101YM0800X
MA6018101YM0800X
CA3902101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL311546OtherLIFESYNCH/CORP HEALTH
FL593439351OtherHUMANA MILITARY
FL9589228OtherAETNA
FL267048OtherCOMPSYNCH
FL2798432OtherUNITED BEHAVIORAL
FL311546OtherAMERIGROUP
FLZ102-XOtherBCBSFL
FL2677850OtherCIGNA