Provider Demographics
NPI:1851867154
Name:WILSON-COLEMAN, ALISA MICHELLE
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:MICHELLE
Last Name:WILSON-COLEMAN
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 1:15290 SW ROYALTY PKWY # 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-4059
Mailing Address - Country:US
Mailing Address - Phone:971-256-4050
Mailing Address - Fax:
Practice Address - Street 1:15290 SW ROYALTY PKWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-4059
Practice Address - Country:US
Practice Address - Phone:971-256-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7278236103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst