Basic Information
| Provider Information | |||||||||
| NPI: | 1932717584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERNANDEZ-QUIROZ | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2400 MOORPARK AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089752730 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2431 W HORIZON RIDGE PKWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890525783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089752730 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2020 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MI4070 | NV | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.