Basic Information
| Provider Information | |||||||||
| NPI: | 1255659421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILMOT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8629 KALAMAZOO RIVER DR | ||||||||
| Address2: | |||||||||
| City: | FOWLERVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488369059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484654335 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26850 PROVIDENCE PKWY | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483741213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484654335 | ||||||||
| FaxNumber: | 2484654535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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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 | 101YP2500X | 6401011483 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.