Provider Demographics
NPI:1447773189
Name:WILSON, LIANNA (PHD)
Entity Type:Individual
Prefix:
First Name:LIANNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 BOYLSTON ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2639
Mailing Address - Country:US
Mailing Address - Phone:617-800-9007
Mailing Address - Fax:
Practice Address - Street 1:729 BOYLSTON ST FL 5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2639
Practice Address - Country:US
Practice Address - Phone:617-800-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA11141103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program