Provider Demographics
NPI:1033831649
Name:STEPHANIE E WILSON LISW-S LLC
Entity Type:Organization
Organization Name:STEPHANIE E WILSON LISW-S LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:704-576-8904
Mailing Address - Street 1:8309 TRAIL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8144
Mailing Address - Country:US
Mailing Address - Phone:704-576-8904
Mailing Address - Fax:
Practice Address - Street 1:90 S HIGH ST STE E
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-1171
Practice Address - Country:US
Practice Address - Phone:614-579-9657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty