Provider Demographics
NPI:1285205427
Name:LOVE, WYLISA M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:WYLISA
Middle Name:M
Last Name:LOVE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:WYLISA
Other - Middle Name:M
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5907 E 44TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-3307
Mailing Address - Country:US
Mailing Address - Phone:773-653-8548
Mailing Address - Fax:
Practice Address - Street 1:5907 E 44TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-3307
Practice Address - Country:US
Practice Address - Phone:773-653-8548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009494A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical