Provider Demographics
NPI:1396395836
Name:WILLCOCKSON, BRETT D (SUDPT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:D
Last Name:WILLCOCKSON
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 N ASH ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2803
Mailing Address - Country:US
Mailing Address - Phone:509-327-3120
Mailing Address - Fax:
Practice Address - Street 1:1321 N ASH ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2803
Practice Address - Country:US
Practice Address - Phone:509-327-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60455856101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077844Medicaid