Provider Demographics
NPI:1619574779
Name:WILSON, LINDSAY ELIZABETH
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:ELIZABETH
Other - Last Name:WACHNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 KOLEPBLA CT
Mailing Address - Street 2:
Mailing Address - City:YONA
Mailing Address - State:GU
Mailing Address - Zip Code:96915-4905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-483-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GURBT-20-135772106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician