Provider Demographics
NPI:1174955629
Name:WILSON, CASSANDRA SUSANN (CDPT)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:SUSANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10828 GRAVELLY LAKE DR. SW
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499
Mailing Address - Country:US
Mailing Address - Phone:253-473-7474
Mailing Address - Fax:253-474-9724
Practice Address - Street 1:10828 GRAVELLY LAKE DR. SW
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-473-7474
Practice Address - Fax:253-474-9724
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60316800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)