Provider Demographics
NPI:1801172481
Name:WILBURN, ALISSE LINLEY (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:ALISSE
Middle Name:LINLEY
Last Name:WILBURN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 N RITTER AVE
Practice Address - Street 2:STE 500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3026
Practice Address - Country:US
Practice Address - Phone:317-359-5467
Practice Address - Fax:317-322-4095
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33006143A104100000X
IN34006861A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201192980AMedicaid