Healthcare Provider Details

I. General information

NPI: 1548051188
Provider Name (Legal Business Name): LISA JEAN WILSON CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

1660 IVY CV
CONWAY AR
72034-8406
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-1653
  • Fax: 501-257-1671
Mailing address:
  • Phone: 501-548-1237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number42922
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: