Provider Demographics
NPI:1780890723
Name:WILSON, INGRID MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:INGRID
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4712 ADMIRALTY WAY
Mailing Address - Street 2:512
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-702-8460
Mailing Address - Fax:877-207-3840
Practice Address - Street 1:3741 STOCKER ST
Practice Address - Street 2:#105
Practice Address - City:VIEW PARK
Practice Address - State:CA
Practice Address - Zip Code:90008-5109
Practice Address - Country:US
Practice Address - Phone:310-702-8460
Practice Address - Fax:877-207-3820
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15620AMedicare ID - Type Unspecified