Provider Demographics
NPI:1326530551
Name:WILSON, BRUCE ALLEN JR (MED)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALLEN
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 BRIDGEPORTWAY W
Mailing Address - Street 2:STE C 2
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466
Mailing Address - Country:US
Mailing Address - Phone:253-625-3959
Mailing Address - Fax:
Practice Address - Street 1:4113 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE C2
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466
Practice Address - Country:US
Practice Address - Phone:253-625-3959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health