Provider Demographics
NPI:1003418716
Name:WILSON, ISABELLA LILLIEPAULINE
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:LILLIEPAULINE
Last Name:WILSON
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 1:2106 CHICORY WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5844
Mailing Address - Country:US
Mailing Address - Phone:775-292-9381
Mailing Address - Fax:
Practice Address - Street 1:9535 OAKLEY LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-6101
Practice Address - Country:US
Practice Address - Phone:775-292-9381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-143190106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician