Provider Demographics
NPI:1114473592
Name:WILSON, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
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 1:1006 E YAGER LN
Mailing Address - Street 2:A 104
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-7088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1006 E YAGER LN
Practice Address - Street 2:A 104
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-7088
Practice Address - Country:US
Practice Address - Phone:512-385-4799
Practice Address - Fax:512-385-4838
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251C00000X, 251S00000X, 253Z00000X
TX5006385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX04-3689304Medicaid