Provider Demographics
NPI:1033457221
Name:WILLSON, LISA MICHELE (MA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELE
Last Name:WILLSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1901
Mailing Address - Country:US
Mailing Address - Phone:610-588-9109
Mailing Address - Fax:
Practice Address - Street 1:51 MARKET ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:PA
Practice Address - Zip Code:18013-1901
Practice Address - Country:US
Practice Address - Phone:610-588-9109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health