Basic Information
| Provider Information | |||||||||
| NPI: | 1265186027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ANDRENIQUE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 E 110TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900591123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234040997 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2116 ARLINGTON AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900181353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233349000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106H00000X | 132269 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.