Healthcare Provider Details

I. General information

NPI: 1114329422
Provider Name (Legal Business Name): LORI ANN WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DR
SPRINGFIELD OR
97477-8803
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-8400
  • Fax: 541-222-8401
Mailing address:
  • Phone: 360-729-1412
  • Fax: 360-729-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA4541
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12-12-68
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberTHW1524
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: