Healthcare Provider Details

I. General information

NPI: 1770610040
Provider Name (Legal Business Name): LISA LANELLE WYLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6412 LAUREL AVE
LAKE ISABELLA CA
93240-9529
US

IV. Provider business mailing address

P.O. BOX 363
WOFFORD HEIGHTS CA
93285
US

V. Phone/Fax

Practice location:
  • Phone: 760-417-1932
  • Fax:
Mailing address:
  • Phone: 760-417-1932
  • Fax: 760-376-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC8528805
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW98599
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS115572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: