Provider Demographics
NPI:1316570427
Name:GRESHAM-WILSON, LISA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:GRESHAM-WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 BELAIR RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1257
Mailing Address - Country:US
Mailing Address - Phone:443-873-7193
Mailing Address - Fax:410-630-7882
Practice Address - Street 1:3301 BELAIR RD STE 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1257
Practice Address - Country:US
Practice Address - Phone:443-873-7193
Practice Address - Fax:410-630-7882
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19313104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker