Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 1454 | WA |
N | 103TB0200X | Cognitive & Behavioral Psychologist | 1454 | WA |
N | 103G00000X | Clinical Psychologist | 1454 | WA |
N | 103TC0700X | Clinical Psychologist | 1454 | WA |
NPI | 1508936931 |
---|---|
Provider Name | Wallace Wilkins |
First Address | Seattle, WA 98104-1058 |
Second Address | Seattle, WA 98104-1008 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2006 |
Last Update Date | 08/07/2007 |