Provider Demographics
NPI:1942449616
Name:WILSON, LISA MARIE (MSW,LCSW, QP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW,LCSW, QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2538
Mailing Address - Country:US
Mailing Address - Phone:910-450-3319
Mailing Address - Fax:910-450-3319
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-3319
Practice Address - Fax:910-450-3319
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007969Medicaid