Provider Demographics
NPI:1578632972
Name:WILSON, MELODY A (RC)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 MORGAN
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122
Mailing Address - Country:US
Mailing Address - Phone:509-725-3469
Mailing Address - Fax:
Practice Address - Street 1:165 E HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2629
Practice Address - Country:US
Practice Address - Phone:509-684-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60145988101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor