Provider Demographics
NPI:1578689840
Name:WILSON, MARY LYNNE (LMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4137 40TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4211
Mailing Address - Country:US
Mailing Address - Phone:206-923-0334
Mailing Address - Fax:206-923-0378
Practice Address - Street 1:3245 FAIRVIEW AVE E
Practice Address - Street 2:SUITE 310
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3053
Practice Address - Country:US
Practice Address - Phone:206-923-0334
Practice Address - Fax:206-923-0378
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006324101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1453WIMedicare UPIN