Provider Demographics
NPI:1649850389
Name:WICK, LISSA A
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:A
Last Name:WICK
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:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-0565
Mailing Address - Country:US
Mailing Address - Phone:360-385-0321
Mailing Address - Fax:
Practice Address - Street 1:884 W PARK AVE
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2273
Practice Address - Country:US
Practice Address - Phone:360-385-0321
Practice Address - Fax:360-379-5534
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 1041C0700X
WASC61160631101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical