Provider Demographics
NPI:1891344255
Name:WILSON, CANSAS ELEANOR (LF 61245115)
Entity Type:Individual
Prefix:
First Name:CANSAS
Middle Name:ELEANOR
Last Name:WILSON
Suffix:
Gender:F
Credentials:LF 61245115
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 1861
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-1861
Mailing Address - Country:US
Mailing Address - Phone:253-651-1361
Mailing Address - Fax:
Practice Address - Street 1:227 S CEDAR ST # 1861
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:WA
Practice Address - Zip Code:98321-2803
Practice Address - Country:US
Practice Address - Phone:253-651-1361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMFTA.MG.61001288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health