Provider Demographics
NPI:1538690953
Name:WILSON, TOMMY LAMAR I
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:LAMAR
Last Name:WILSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-6014
Mailing Address - Country:US
Mailing Address - Phone:509-838-6092
Mailing Address - Fax:509-838-6110
Practice Address - Street 1:701 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-6014
Practice Address - Country:US
Practice Address - Phone:509-838-6092
Practice Address - Fax:509-838-6110
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 60618611101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)