Provider Demographics
NPI:1629732607
Name:WILSON, REBECCA LYNNE (LMT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
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 508
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98235-0508
Mailing Address - Country:US
Mailing Address - Phone:360-856-5562
Mailing Address - Fax:
Practice Address - Street 1:22790 BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-8023
Practice Address - Country:US
Practice Address - Phone:360-856-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61229053225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist