Provider Demographics
NPI:1386611168
Name:WILSON, BRENDA MARIE (MS)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12009 133RD ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-4698
Mailing Address - Country:US
Mailing Address - Phone:253-845-3028
Mailing Address - Fax:
Practice Address - Street 1:12009 133RD ST E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-4698
Practice Address - Country:US
Practice Address - Phone:253-845-3028
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9513101YA0400X
WA30943101YM0800X
TX30943103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist