Provider Demographics
NPI:1104259167
Name:WILSON, DAVID LAWRENCE (CDP)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:WILSON
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0997
Mailing Address - Country:US
Mailing Address - Phone:509-837-7700
Mailing Address - Fax:509-838-7311
Practice Address - Street 1:702 E. FRANKLIN AVENUE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-0997
Practice Address - Country:US
Practice Address - Phone:509-837-7700
Practice Address - Fax:509-838-7311
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00002873101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)