Provider Demographics
NPI:1013331636
Name:WILSON, JOE LOUIS (LMP)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:LOUIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9414 RIDGETOP BLVD NW
Mailing Address - Street 2:#101
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8525
Mailing Address - Country:US
Mailing Address - Phone:360-308-0250
Mailing Address - Fax:360-308-0195
Practice Address - Street 1:9414 RIDGETOP BLVD NW
Practice Address - Street 2:#101
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8525
Practice Address - Country:US
Practice Address - Phone:360-308-0250
Practice Address - Fax:360-308-0195
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60442140225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist