Provider Demographics
NPI:1164630851
Name:WILSON, LYNN A (MA)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:A
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:631 5TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-1581
Mailing Address - Country:US
Mailing Address - Phone:425-355-1698
Mailing Address - Fax:425-355-1698
Practice Address - Street 1:631 5TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-1581
Practice Address - Country:US
Practice Address - Phone:425-355-1698
Practice Address - Fax:425-355-1698
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005995101YM0800X
WALF00000888106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1304204OtherITIN