Provider Demographics
NPI:1033567417
Name:WILSON, LISA MARIE (IMF/MFT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:IMF/MFT
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WILSON-BYRNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:IMF/MFT
Mailing Address - Street 1:525 N PARKER ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-1323
Mailing Address - Country:US
Mailing Address - Phone:714-639-5546
Mailing Address - Fax:
Practice Address - Street 1:525 N PARKER ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-1323
Practice Address - Country:US
Practice Address - Phone:714-639-5542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF89029106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist