Provider Demographics
NPI:1437559549
Name:WILSON, SHIRA BETH (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:BETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:SHIRA
Other - Middle Name:
Other - Last Name:WILSON-GROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LMHC
Mailing Address - Street 1:PO BOX 25041
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98165-1941
Mailing Address - Country:US
Mailing Address - Phone:206-769-6584
Mailing Address - Fax:
Practice Address - Street 1:3245 FAIRVIEW AVE E
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3053
Practice Address - Country:US
Practice Address - Phone:206-769-6584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60488602101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health