Provider Demographics
NPI:1992152995
Name:WILSON, LAURREL SUSAN (CDP)
Entity type:Individual
Prefix:
First Name:LAURREL
Middle Name:SUSAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:LAURI
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CDP
Mailing Address - Street 1:5900 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-1409
Mailing Address - Country:US
Mailing Address - Phone:509-572-0633
Mailing Address - Fax:
Practice Address - Street 1:5900 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-1409
Practice Address - Country:US
Practice Address - Phone:509-572-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60604431101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional