Healthcare Provider Details

I. General information

NPI: 1922924935
Provider Name (Legal Business Name): BONNIE R WILSON CDPT.CO.61645756
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 N 20TH AVE
PASCO WA
99301-3393
US

IV. Provider business mailing address

1202 W ENTIAT AVE APT A101
KENNEWICK WA
99336-3489
US

V. Phone/Fax

Practice location:
  • Phone: 509-792-1041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDPT.CO.61645756
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: