Provider Demographics
NPI:1811138456
Name:WILSON, SOPHIA RACHELLE (NONE)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:RACHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4137 BAINE AVE APT 212C
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4878
Mailing Address - Country:US
Mailing Address - Phone:510-897-2707
Mailing Address - Fax:
Practice Address - Street 1:2853 GROOM DR
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-2664
Practice Address - Country:US
Practice Address - Phone:510-222-3946
Practice Address - Fax:510-222-3986
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor