Provider Demographics
NPI:1649667692
Name:WILSON, MATTHEW RYAN (LBA, BCBA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 130TH AVE NE STE 202
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-1761
Mailing Address - Country:US
Mailing Address - Phone:425-882-8868
Mailing Address - Fax:
Practice Address - Street 1:2310 130TH AVE NE STE 202
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-1761
Practice Address - Country:US
Practice Address - Phone:425-882-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA60928333103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst