Provider Demographics
NPI:1538719216
Name:WILSON, LISA (LPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4680 SAINT JAMES WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-2248
Mailing Address - Country:US
Mailing Address - Phone:678-902-5472
Mailing Address - Fax:
Practice Address - Street 1:2849B HENDERSON MILL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-5772
Practice Address - Country:US
Practice Address - Phone:647-902-5472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011140101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional