Provider Demographics
NPI:1255799003
Name:THE WILSON GONZALEZ CENTER FOR NEUROEDUCATION AND STUDENT DRIVEN LEARN
Entity type:Organization
Organization Name:THE WILSON GONZALEZ CENTER FOR NEUROEDUCATION AND STUDENT DRIVEN LEARN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NEURODEVELOPMENTAL SYSTEMS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ERIN
Authorized Official - Last Name:WILSON GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MED
Authorized Official - Phone:910-987-0203
Mailing Address - Street 1:930 ROSS LOOP
Mailing Address - Street 2:D325
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-9044
Mailing Address - Country:US
Mailing Address - Phone:910-987-0203
Mailing Address - Fax:
Practice Address - Street 1:1460 WILMINGTON DR
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-8838
Practice Address - Country:US
Practice Address - Phone:910-987-0203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty