Provider Demographics
NPI:1881823045
Name:WILSON, SAMANTHA DEWITT (PSYD, LCSW)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:DEWITT
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10085 CARROLL CANYON RD STE 200H
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1100
Mailing Address - Country:US
Mailing Address - Phone:858-208-3463
Mailing Address - Fax:
Practice Address - Street 1:10085 CARROLL CANYON RD STE 200H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1100
Practice Address - Country:US
Practice Address - Phone:858-208-3463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34430103T00000X
CA763891041C0700X
CAPSY34430103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty