Provider Demographics
NPI:1134340714
Name:WILSON, LORI ANNE (PSYD, PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD, PSYCHOLOGIST
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:ANNE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:6020 W BELL RD # 108
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3770
Mailing Address - Country:US
Mailing Address - Phone:602-500-1302
Mailing Address - Fax:
Practice Address - Street 1:6020 W BELL RD # 108
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3770
Practice Address - Country:US
Practice Address - Phone:602-500-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ5470103TC0700X
AZ5470103TB0200X, 103TC0700X
103TS0200X
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral