Basic Information
| Provider Information | |||||||||
| NPI: | 1396395836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLCOCKSON | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | SUDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 N ASH ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093273120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1321 N ASH ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093273120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2019 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60455856 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2077844 | 05 | WA | MEDICAID |