Provider Demographics
NPI:1053929596
Name:WILBURN, ANGELA RENAE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENAE
Last Name:WILBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25630 46TH AVE S
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-9713
Mailing Address - Country:US
Mailing Address - Phone:206-852-1728
Mailing Address - Fax:
Practice Address - Street 1:111 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1108
Practice Address - Country:US
Practice Address - Phone:360-240-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician