Provider Demographics
NPI:1285279257
Name:WILSON, TANAYSHA EBONY (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:TANAYSHA
Middle Name:EBONY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8706 PELLINGTON PL APT 7
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4835
Mailing Address - Country:US
Mailing Address - Phone:804-319-5938
Mailing Address - Fax:
Practice Address - Street 1:2025 E MAIN ST STE 15
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7069
Practice Address - Country:US
Practice Address - Phone:877-707-5220
Practice Address - Fax:888-519-4656
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040113601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical