Provider Demographics
NPI:1336687805
Name:WILMORE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 PARKWOOD ST
Mailing Address - Street 2:APT #C305
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6132
Mailing Address - Country:US
Mailing Address - Phone:616-540-8348
Mailing Address - Fax:
Practice Address - Street 1:3522 BRIAR CREEK LN
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4728
Practice Address - Country:US
Practice Address - Phone:208-529-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-05
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID112520007Medicaid
ID112520007Medicaid