Provider Demographics
NPI:1902089972
Name:WILSON, MICHAEL LAWRENCE (AA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:WILSON
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5623 N 49TH ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98407-3014
Mailing Address - Country:US
Mailing Address - Phone:235-548-9728
Mailing Address - Fax:
Practice Address - Street 1:3834 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2016
Practice Address - Country:US
Practice Address - Phone:253-396-5901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health