Provider Demographics
NPI:1043682594
Name:WILSON, CIARA (LMP)
Entity Type:Individual
Prefix:
First Name:CIARA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 S MAIERS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-8818
Mailing Address - Country:US
Mailing Address - Phone:509-764-8626
Mailing Address - Fax:509-764-8628
Practice Address - Street 1:2200 S MAIERS RD
Practice Address - Street 2:SUITE B
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-8818
Practice Address - Country:US
Practice Address - Phone:509-764-8626
Practice Address - Fax:509-764-8628
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60428062225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist