Provider Demographics
NPI:1891197125
Name:WIMBERLY, LANCE (LMSW)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:
Last Name:WIMBERLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 RIVERSHELL LN
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-1907
Mailing Address - Country:US
Mailing Address - Phone:614-657-4924
Mailing Address - Fax:517-853-0415
Practice Address - Street 1:1001 DAKIN ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1911
Practice Address - Country:US
Practice Address - Phone:517-853-9897
Practice Address - Fax:517-853-0415
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010922771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical