Provider Demographics
NPI:1174090229
Name:WILSON, CARLA GWEN (MHRS, MA, PPS)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:GWEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MHRS, MA, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 CREEKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-4635
Mailing Address - Country:US
Mailing Address - Phone:408-509-9602
Mailing Address - Fax:
Practice Address - Street 1:516 CREEKSIDE LN
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-4635
Practice Address - Country:US
Practice Address - Phone:408-509-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 174H00000X, 101YS0200X, 171M00000X, 101Y00000X
CA101YA0400X, 101YM0800X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174H00000XOther Service ProvidersHealth Educator
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator