Provider Demographics
NPI:1508391707
Name:WILSON, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-1359
Mailing Address - Country:US
Mailing Address - Phone:661-300-1806
Mailing Address - Fax:
Practice Address - Street 1:1800 112TH AVE NE
Practice Address - Street 2:SUITE 260E
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-2993
Practice Address - Country:US
Practice Address - Phone:425-642-2153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWILSOKE076RJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst