Provider Demographics
NPI:1003278763
Name:WILSON, CASSANDRA E
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:E
Other - Last Name:MCVAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6109 55TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4107
Mailing Address - Country:US
Mailing Address - Phone:425-350-2188
Mailing Address - Fax:
Practice Address - Street 1:6109 55TH AVE NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4107
Practice Address - Country:US
Practice Address - Phone:425-350-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61100829106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist