Provider Demographics
NPI:1790905008
Name:WILSON, LISA RENEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:RENEE
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:PO BOX 685
Mailing Address - Street 2:
Mailing Address - City:CITRA
Mailing Address - State:FL
Mailing Address - Zip Code:32113
Mailing Address - Country:US
Mailing Address - Phone:352-425-8454
Mailing Address - Fax:
Practice Address - Street 1:2091 NE 35TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34479-2909
Practice Address - Country:US
Practice Address - Phone:352-732-1355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 10251104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766681100Medicaid