Provider Demographics
NPI:1477926822
Name:WILSON, LAUREN (LCSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S WAKEA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-1385
Mailing Address - Country:US
Mailing Address - Phone:808-264-3007
Mailing Address - Fax:
Practice Address - Street 1:135 S WAKEA AVE STE 101
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1385
Practice Address - Country:US
Practice Address - Phone:808-264-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-06
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI40791041C0700X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist