Provider Demographics
NPI:1770610040
Name:WYLY, LISA LANELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LANELLE
Last Name:WYLY
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 363
Mailing Address - Street 2:
Mailing Address - City:WOFFORD HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:93285
Mailing Address - Country:US
Mailing Address - Phone:760-417-1932
Mailing Address - Fax:760-376-3034
Practice Address - Street 1:6412 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9529
Practice Address - Country:US
Practice Address - Phone:760-417-1932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC8528805101YA0400X
CAASW985991041C0700X
CALCS1155721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)