Healthcare Provider Details

I. General information

NPI: 1013096643
Provider Name (Legal Business Name): LISA H WILSON MS, SC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12337 HANCOCK ST STE 20
CARMEL IN
46032-5885
US

IV. Provider business mailing address

12337 HANCOCK ST STE 20
CARMEL IN
46032-5885
US

V. Phone/Fax

Practice location:
  • Phone: 317-706-6744
  • Fax: 317-706-6700
Mailing address:
  • Phone: 317-706-6744
  • Fax: 317-706-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002889A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: