Provider Demographics
NPI:1417010364
Name:WILSON, GREGORY L (PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 SE BISHOP BLVD STE Q
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5439
Mailing Address - Country:US
Mailing Address - Phone:509-334-0782
Mailing Address - Fax:509-334-0361
Practice Address - Street 1:1240 SE BISHOP BLVD STE Q
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5439
Practice Address - Country:US
Practice Address - Phone:509-334-0782
Practice Address - Fax:509-334-0361
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001308103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7066996Medicaid