Provider Demographics
NPI:1750552964
Name:WILSON, ELISSA ANN (LMFT, LAADC)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT, LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14120 HAMLIN ST APT 12
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1404
Mailing Address - Country:US
Mailing Address - Phone:818-984-2510
Mailing Address - Fax:
Practice Address - Street 1:14120 HAMLIN ST APT 12
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1404
Practice Address - Country:US
Practice Address - Phone:818-984-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA135593106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist