Provider Demographics
NPI:1639528169
Name:WILSON, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ANN
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3214 W MCGRAW ST STE 306
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-3239
Mailing Address - Country:US
Mailing Address - Phone:206-453-4882
Mailing Address - Fax:
Practice Address - Street 1:1570 WILMINGTON DR
Practice Address - Street 2:220
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-8773
Practice Address - Country:US
Practice Address - Phone:253-507-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician