MEDICARE: MR. BRYCE WILSON MA, LMHC, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LH00010388	WA

General Provider Information

NPI Number	:	1952582843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYCE WILSON MA, LMHC, LMFT

Provider Business Mailing Address
First Line	:	5620 112TH ST E
Second Line	:	STE. 215
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3206
Country	:	US
Telephone Number	:	253-446-7176
Fax Number	:

Provider Business Practice Location Address
First Line	:	5620 112TH ST E
Second Line	:	STE. 215
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3206
Country	:	US
Telephone Number	:	253-446-7176
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2007
Last Update Date	:	06/08/2016

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