Provider Demographics
NPI:1205581774
Name:WILSON, CYNTHIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
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 1:7424 BRIDGEPORT WAY W STE 305
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8135
Mailing Address - Country:US
Mailing Address - Phone:253-246-6820
Mailing Address - Fax:
Practice Address - Street 1:7424 BRIDGEPORT WAY W STE 305
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8135
Practice Address - Country:US
Practice Address - Phone:253-246-6820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61253334101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor