Basic Information
Provider Information | |||||||||
NPI: | 1508324161 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | ALISA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOVATO | ||||||||
OtherFirstName: | ALISA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 330 | ||||||||
Address2: |   | ||||||||
City: | MAGNA | ||||||||
State: | UT | ||||||||
PostalCode: | 840440330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019904300 | ||||||||
FaxNumber: | 8019672127 | ||||||||
Practice Location | |||||||||
Address1: | 11075 S STATE ST STE 35 | ||||||||
Address2: |   | ||||||||
City: | SANDY | ||||||||
State: | UT | ||||||||
PostalCode: | 840705187 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019904300 | ||||||||
FaxNumber: | 8019672127 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2019 | ||||||||
LastUpdateDate: | 02/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 328353-6009 | UT | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.