Provider Demographics
NPI:1851626998
Name:WILSON, LORI L (LCSW)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:415 WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-2116
Mailing Address - Country:US
Mailing Address - Phone:207-667-5357
Mailing Address - Fax:207-667-0174
Practice Address - Street 1:415 WATER ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-2116
Practice Address - Country:US
Practice Address - Phone:207-667-5357
Practice Address - Fax:207-667-0174
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC118861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical