Provider Demographics
NPI:1629224902
Name:WOLCOTT, LISA R
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:WOLCOTT
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 1:2610 NW 43RD ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6675
Mailing Address - Country:US
Mailing Address - Phone:352-871-1297
Mailing Address - Fax:352-378-7849
Practice Address - Street 1:2610 NW 43RD ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6675
Practice Address - Country:US
Practice Address - Phone:352-871-1297
Practice Address - Fax:352-378-7849
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 89391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical