Healthcare Provider Details

I. General information

NPI: 1568983252
Provider Name (Legal Business Name): SAMANTHA LA WILSON CDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28115 SE 451ST ST
ENUMCLAW WA
98022-9204
US

IV. Provider business mailing address

100 WELLNESS WAY
NEAH BAY WA
98357
US

V. Phone/Fax

Practice location:
  • Phone: 360-640-5312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60757690
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: