Provider Demographics
NPI:1669441432
Name:WILSON, RANDY LEE (LMSW)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 83RD STREET CT SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-4757
Mailing Address - Country:US
Mailing Address - Phone:253-651-4934
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF THE ARMY: COMMANDER
Practice Address - Street 2:MADIGAN ARMY MEDICAL CENTER ATTN: MCHJ-SW
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-2303
Practice Address - Fax:253-968-1151
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1994631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical