Basic Information
| Provider Information | |||||||||
| NPI: | 1114329422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291412 | ||||||||
| FaxNumber: | 3607293025 | ||||||||
| Practice Location | |||||||||
| Address1: | 3377 RIVERBEND DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974778803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412228400 | ||||||||
| FaxNumber: | 5412228401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | A4541 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 12-12-68 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 175T00000X | THW1524 | OR | N |
ID Information
| ID | Type | State | Issuer | Description | 500679239 | 05 | OR | MEDICAID |