Provider Demographics
NPI:1679004451
Name:WILSON, CASSANDRA MARY (MA, MHP, EMMHS)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MARY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, MHP, EMMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 204TH ST SW APT A102
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-9311
Mailing Address - Country:US
Mailing Address - Phone:206-859-0813
Mailing Address - Fax:
Practice Address - Street 1:16150 NE 85TH ST STE 220
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3546
Practice Address - Country:US
Practice Address - Phone:425-558-0558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC 60696501102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst