| Doctor Name: | CLARENCE CARL WILSON |
| NPI Number: | 1033496245 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LPCC, CADC |
| License Number: | 6159 |
| Business Practice Address: | 400 S 2nd Ave Ste 105 Barstow, CA - 923112854 |
| Business Phone Number: | 3146623883 |
| Business Fax Number: | |
| Mailing Address: | 14549 Lighthouse #567, Box 567 HELENDALE |
| State: | CA |
| Postal Code: | 92342 |
| Phone Number: | 3146623883 |
| Fax Number: | |
| NPI Enumeration Date: | 11/16/2011 |
| NPI Last Update Date: | 05/26/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 6159 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |