Provider Demographics
NPI:1144550518
Name:WILSON, DANIEL LAVELLE
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LAVELLE
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 1:7171 BOWLING DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2043
Mailing Address - Country:US
Mailing Address - Phone:916-394-9195
Mailing Address - Fax:916-392-2827
Practice Address - Street 1:CSH WELLNESS & RECOVERY
Practice Address - Street 2:7171 BOWLING DR. STE 300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823
Practice Address - Country:US
Practice Address - Phone:916-394-9195
Practice Address - Fax:916-392-2827
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health