Provider Demographics
NPI:1174632905
Name:WILSON, MAYA JEAN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MAYA
Middle Name:JEAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 ADELE AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-3521
Mailing Address - Country:US
Mailing Address - Phone:360-782-0129
Mailing Address - Fax:360-377-8029
Practice Address - Street 1:925 ADELE AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-3521
Practice Address - Country:US
Practice Address - Phone:360-782-0129
Practice Address - Fax:360-377-8029
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000051341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical