Provider Demographics
NPI:1194004481
Name:SWAILS, LISETTE WILCOX (PHD- LP)
Entity Type:Individual
Prefix:DR
First Name:LISETTE
Middle Name:WILCOX
Last Name:SWAILS
Suffix:
Gender:F
Credentials:PHD- LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 RAINBOW BLVD
Mailing Address - Street 2:KUMC-CCHD MS 4003
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66103-2917
Mailing Address - Country:US
Mailing Address - Phone:913-588-5922
Mailing Address - Fax:
Practice Address - Street 1:3903 RAINBOW BLVD
Practice Address - Street 2:KUMC-CCHD MS 4003
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66103-2917
Practice Address - Country:US
Practice Address - Phone:913-588-5922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2396103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1841281805OtherCENTER NPI