MEDICARE: MRS. LISA LANELLE WYLY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	C8528805	CA
2	1041C0700X	Clinical Social Worker	ASW98599	CA
3	1041C0700X	Clinical Social Worker	LCS115572	CA

General Provider Information

NPI Number	:	1770610040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA LANELLE WYLY LCSW

Provider Business Mailing Address
First Line	:	P.O. BOX 363
Second Line	:
City	:	WOFFORD HEIGHTS
State	:	CA
Zip	:	93285
Country	:	US
Telephone Number	:	760-417-1932
Fax Number	:	760-376-3034

Provider Business Practice Location Address
First Line	:	6412 LAUREL AVE
Second Line	:
City	:	LAKE ISABELLA
State	:	CA
Zip	:	93240-9529
Country	:	US
Telephone Number	:	760-417-1932
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	04/18/2025

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