Provider Demographics
NPI:1952008435
Name:WILSON, AIDAN T
Entity type:Individual
Prefix:
First Name:AIDAN
Middle Name:T
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54275 AVENIDA VELASCO
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-3661
Mailing Address - Country:US
Mailing Address - Phone:760-702-5869
Mailing Address - Fax:
Practice Address - Street 1:54275 AVENIDA VELASCO
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-3661
Practice Address - Country:US
Practice Address - Phone:760-702-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician