Provider Demographics
NPI:1912112335
Name:WILSON, MICHAL CAROLYN (PSY D)
Entity Type:Individual
Prefix:DR
First Name:MICHAL
Middle Name:CAROLYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21545 CENTRE POINTE PKWY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91350-2947
Mailing Address - Country:US
Mailing Address - Phone:661-259-9439
Mailing Address - Fax:
Practice Address - Street 1:21545 CENTRE POINTE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91350-2947
Practice Address - Country:US
Practice Address - Phone:661-259-9439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34175103TC2200X, 103TC0700X
NE8162101YM0800X
CAWAIVER390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program