Provider Demographics
NPI:1154770329
Name:BRYCE WILSON, PLLC
Entity type:Organization
Organization Name:BRYCE WILSON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC, LMFT
Authorized Official - Phone:253-446-7176
Mailing Address - Street 1:5620 112TH ST E
Mailing Address - Street 2:STE. 215
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3206
Mailing Address - Country:US
Mailing Address - Phone:253-446-7176
Mailing Address - Fax:253-446-7176
Practice Address - Street 1:5620 112TH ST E
Practice Address - Street 2:STE. 215
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3206
Practice Address - Country:US
Practice Address - Phone:253-446-7176
Practice Address - Fax:253-446-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010388101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty