Provider Demographics
NPI:1255659421
Name:WILMOT, LISA (LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILMOT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8629 KALAMAZOO RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-9059
Mailing Address - Country:US
Mailing Address - Phone:248-465-4335
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-465-4335
Practice Address - Fax:248-465-4535
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011483101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional