Provider Demographics
NPI:1689440026
Name:WILSON, CASPER S
Entity type:Individual
Prefix:
First Name:CASPER
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:ANN
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 N JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1211 W VISTA WAY BLDG C
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6227
Practice Address - Country:US
Practice Address - Phone:760-721-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1560290524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty