1821134271 NPI number — MS. TERRA RENNE WILSON SAC II

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821134271 NPI number — MS. TERRA RENNE WILSON SAC II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
TERRA
Provider Middle Name:
RENNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
SAC II
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOODRICH
Provider Other First Name:
TERRA
Provider Other Middle Name:
RENNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RASI
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821134271
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9345 WINCHESTER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWER LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95457-5720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-995-3235
Provider Business Mailing Address Fax Number:
707-995-7004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9345 WINCHESTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOWER LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-995-3235
Provider Business Practice Location Address Fax Number:
707-995-7004
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: RI-G0505091545 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RI-G0505091545 . This is a "SUBSTANCE ABUSE DISORDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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