Provider Demographics
NPI:1629256409
Name:WILSON, LORI SUE (MSW, LISAC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:SUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7464 S NEVIL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-2565
Mailing Address - Country:US
Mailing Address - Phone:520-883-6105
Mailing Address - Fax:520-883-6105
Practice Address - Street 1:2480 N PALO VERDE BLVD
Practice Address - Street 2:#103
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2548
Practice Address - Country:US
Practice Address - Phone:520-322-6980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11771101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)