Provider Demographics
NPI:1932732906
Name:WILSKE, TERI LEE (LSW)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:LEE
Last Name:WILSKE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 BARTON RD TRLR 35
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-1827
Mailing Address - Country:US
Mailing Address - Phone:208-240-8540
Mailing Address - Fax:
Practice Address - Street 1:845 BARTON RD TRLR 35
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-1827
Practice Address - Country:US
Practice Address - Phone:208-240-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-27997104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker