Provider Demographics
NPI:1730797028
Name:WILSON, KRYSTAL R
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:R
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 1:314 182ND AVE E UNIT C
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-5704
Mailing Address - Country:US
Mailing Address - Phone:253-501-6300
Mailing Address - Fax:
Practice Address - Street 1:314 182ND AVE E UNIT C
Practice Address - Street 2:
Practice Address - City:LAKE TAPPS
Practice Address - State:WA
Practice Address - Zip Code:98391-5704
Practice Address - Country:US
Practice Address - Phone:253-501-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor