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General NPI Number Information
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NPI Number | 1790905008
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Entity Type | Individual
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Provider Name | LISA RENEE WILSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 04/27/2007
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Last Update Date | 04/11/2013
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Provider Practice Location Address
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Address Line | 2091 NE 35TH ST
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City | OCALA
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State | FL
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Zip | 34479-2909
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Country | US
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Telephone | 352-732-1355
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 685
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City | CITRA
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State | FL
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Zip | 32113
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Country | US
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Telephone | 352-425-8454
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | SW 10251
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License Number State | FL
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