Individual
LISA WILMORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3522 BRIAR CREEK LN, AMMON, ID 83406-4728
(208) 529-1660
Mailing address
1900 PARKWOOD ST, APT #C305, IDAHO FALLS, ID 83401-6132
(616) 540-8348
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
112520007
—
ID
Enumeration date
02/05/2017
Last updated
04/26/2017
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