Provider Demographics
NPI:1235386699
Name:WILSON, LISA ELAINE (LPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:E
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:1052 GARDNER RD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5702
Mailing Address - Country:US
Mailing Address - Phone:843-628-6334
Mailing Address - Fax:843-628-6334
Practice Address - Street 1:1052 GARDNER RD STE 700
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5702
Practice Address - Country:US
Practice Address - Phone:843-628-6334
Practice Address - Fax:843-628-6334
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4014101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional