Provider Demographics
NPI:1720405343
Name:WILSON, CHERYL
Entity Type:Individual
Prefix:
First Name:CHERYL
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 1:9608 NE 132ND AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-2912
Mailing Address - Country:US
Mailing Address - Phone:360-904-8540
Mailing Address - Fax:
Practice Address - Street 1:9300 NE OAK VIEW DR
Practice Address - Street 2:SUITE B
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6192
Practice Address - Country:US
Practice Address - Phone:360-567-2211
Practice Address - Fax:360-567-2212
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60764006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health