Provider Demographics
NPI:1841644564
Name:WILSON, RONIQUE GORDON (PHD)
Entity type:Individual
Prefix:DR
First Name:RONIQUE
Middle Name:GORDON
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 1:4715 VIEWRIDGE AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1680
Mailing Address - Country:US
Mailing Address - Phone:800-257-8715
Mailing Address - Fax:858-408-7133
Practice Address - Street 1:4650 S PANTHER CREEK DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-2764
Practice Address - Country:US
Practice Address - Phone:281-363-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35002103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling