Healthcare Provider Details

I. General information

NPI: 1639216120
Provider Name (Legal Business Name): MOLLI MARIE WILSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17121 SE 270TH PL SUITE 205
COVINGTON WA
98042
US

IV. Provider business mailing address

PO BOX 402
MAPLE VALLEY WA
98038
US

V. Phone/Fax

Practice location:
  • Phone: 425-413-8970
  • Fax: 253-638-7465
Mailing address:
  • Phone: 425-413-8970
  • Fax: 253-638-7465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY00003780
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00005493
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: