Provider Demographics
NPI:1093266058
Name:WILSON, DENISE (CDP)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 FALK RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-5604
Mailing Address - Country:US
Mailing Address - Phone:360-750-9588
Mailing Address - Fax:
Practice Address - Street 1:888 S HILLHURST RD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-9063
Practice Address - Country:US
Practice Address - Phone:360-887-6060
Practice Address - Fax:360-727-3638
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60509166101YA0400X
WACP60772363101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)