Provider Demographics
NPI:1881878916
Name:WILSON, LISA DIANE (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11642 GARNETT ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-3435
Mailing Address - Country:US
Mailing Address - Phone:913-370-6541
Mailing Address - Fax:
Practice Address - Street 1:21350 W 153RD ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5413
Practice Address - Country:US
Practice Address - Phone:913-322-2400
Practice Address - Fax:913-621-5730
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LP1703103TC2200X
KSLP03197103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent