1255799003 NPI number — THE WILSON GONZALEZ CENTER FOR NEUROEDUCATION AND STUDENT DRIVEN LEARN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255799003 NPI number — THE WILSON GONZALEZ CENTER FOR NEUROEDUCATION AND STUDENT DRIVEN LEARN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WILSON GONZALEZ CENTER FOR NEUROEDUCATION AND STUDENT DRIVEN LEARN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WGCN
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255799003
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 ROSS LOOP
Provider Second Line Business Mailing Address:
D325
Provider Business Mailing Address City Name:
DUPONT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98327-9044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-987-0203
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1460 WILMINGTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUPONT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98327-8838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-987-0203
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON GONZALEZ
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
ERIN
Authorized Official Title or Position:
NEURODEVELOPMENTAL SYSTEMS DIRECTOR
Authorized Official Telephone Number:
910-987-0203

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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