Provider Demographics
NPI:1477914281
Name:WISDOM, LORI MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:MICHELLE
Last Name:WISDOM
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 1:7326 RAINIER DR APT 7
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-5756
Mailing Address - Country:US
Mailing Address - Phone:425-791-4082
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-8359
Practice Address - Fax:425-349-8348
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWISDOLM213KD101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA201596274Medicaid