Provider Demographics
NPI:1528346640
Name:WILSON, LISA MICHELE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CAGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:900 PACIFIC AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4168
Practice Address - Country:US
Practice Address - Phone:425-258-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60117765235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist