Basic Information
| Provider Information | |||||||||
| NPI: | 1003882705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LEO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 N RAYMOND RD | ||||||||
| Address2: | STE 20 | ||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992066832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099261770 | ||||||||
| FaxNumber: | 5092289542 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 S FREYA ST | ||||||||
| Address2: | STE 215B ORANGE FLAG BLDG | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095352048 | ||||||||
| FaxNumber: | 5095352046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH00007082 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.