Provider Demographics
NPI:1922215474
Name:WILSON, LORI M
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:M
Last Name:WILSON
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 1:3236 WYOMING BLVD NE APT 11B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-9443
Mailing Address - Country:US
Mailing Address - Phone:505-410-2391
Mailing Address - Fax:
Practice Address - Street 1:7801 ACADEMY NE
Practice Address - Street 2:BLDG 2 SUITE 200
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-273-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No246RH0600XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyHistology