Provider Demographics
NPI:1639216120
Name:WILSON, MOLLI MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MOLLI
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
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 402
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038
Mailing Address - Country:US
Mailing Address - Phone:425-413-8970
Mailing Address - Fax:253-638-7465
Practice Address - Street 1:17121 SE 270TH PL
Practice Address - Street 2:SUITE 205
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042
Practice Address - Country:US
Practice Address - Phone:425-413-8970
Practice Address - Fax:253-638-7465
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003780103T00000X
WALW000054931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical