Basic Information
| Provider Information | |||||||||
| NPI: | 1588952204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.A., LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 153 | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910170153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185249282 | ||||||||
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| Practice Location | |||||||||
| Address1: | 507 W FOOTHILL BLVD # B | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910162021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264277357 | ||||||||
| FaxNumber: | 8182435431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 93754 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.