Provider Demographics
NPI:1295042109
Name:WILSON, SANDY KAY (D MIN)
Entity Type:Individual
Prefix:DR
First Name:SANDY
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:D MIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8305 SE MONTEREY AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7753
Mailing Address - Country:US
Mailing Address - Phone:503-659-4082
Mailing Address - Fax:503-659-4951
Practice Address - Street 1:8305 SE MONTEREY AVE STE 220
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7753
Practice Address - Country:US
Practice Address - Phone:503-659-4082
Practice Address - Fax:503-659-4951
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor