Provider Demographics
NPI:1619283520
Name:WILSON, LLORY
Entity Type:Individual
Prefix:
First Name:LLORY
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 1:1809 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-7610
Mailing Address - Country:US
Mailing Address - Phone:360-379-5109
Mailing Address - Fax:360-385-2684
Practice Address - Street 1:1809 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-7610
Practice Address - Country:US
Practice Address - Phone:360-379-5109
Practice Address - Fax:360-385-2684
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60766344101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health