Provider Demographics
NPI:1255864583
Name:WILSON, GWENDOLYN (LMHC, ATR)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC, ATR
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC, ATR
Mailing Address - Street 1:1200 12TH AVE S STE 901
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2712
Mailing Address - Country:US
Mailing Address - Phone:206-548-3114
Mailing Address - Fax:
Practice Address - Street 1:1833 N 105TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8973
Practice Address - Country:US
Practice Address - Phone:206-888-4437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60672915101YM0800X
WALH60963777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health