Healthcare Provider Details

I. General information

NPI: 1720405343
Provider Name (Legal Business Name): CHERYL WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 NE OAK VIEW DR SUITE B
VANCOUVER WA
98662-6192
US

IV. Provider business mailing address

9608 NE 132ND AVE
VANCOUVER WA
98682-2912
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax: 360-567-2212
Mailing address:
  • Phone: 360-904-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60764006
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: