Provider Demographics
NPI:1366217762
Name:WILKS, KEITH MADISON (COUNSELOR)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MADISON
Last Name:WILKS
Suffix:
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 GINA CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-7743
Mailing Address - Country:US
Mailing Address - Phone:360-999-9080
Mailing Address - Fax:
Practice Address - Street 1:842 GINA CT SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98513-7743
Practice Address - Country:US
Practice Address - Phone:360-999-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61094671101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor