Basic Information
| Provider Information | |||||||||
| NPI: | 1003006362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MABRY WILSON | ||||||||
| FirstName: | MICHELE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5674 STONERIDGE DR | ||||||||
| Address2: | # 116 | ||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945888500 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 411 30TH ST | ||||||||
| Address2: | #314 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102734200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.