Provider Demographics
NPI:1780234948
Name:WILSON, THERESA MARIE (MA)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:WILLIAMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11512 B AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2605
Mailing Address - Country:US
Mailing Address - Phone:530-889-7289
Mailing Address - Fax:
Practice Address - Street 1:11512 B AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2605
Practice Address - Country:US
Practice Address - Phone:530-889-7275
Practice Address - Fax:530-889-7293
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator