Provider Demographics
NPI:1720208978
Name:WILSON, LORILYN A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LORILYN
Middle Name:A
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 1:497 BEAHAN RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3403
Mailing Address - Country:US
Mailing Address - Phone:585-746-1500
Mailing Address - Fax:585-278-1196
Practice Address - Street 1:497 BEAHAN RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-3403
Practice Address - Country:US
Practice Address - Phone:585-746-1500
Practice Address - Fax:585-278-1196
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0483951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11334655OtherCAQH
NYIA0473Medicare ID - Type Unspecified
NYQ11025Medicare UPIN