Provider Demographics
NPI:1629950902
Name:WILSON, LATISHA SHAMALA (BEH TECHN ICIAN)
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:SHAMALA
Last Name:WILSON
Suffix:
Gender:F
Credentials:BEH TECHN ICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 N JEFFERSON ST APT 4
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-1519
Mailing Address - Country:US
Mailing Address - Phone:813-405-7097
Mailing Address - Fax:813-405-7097
Practice Address - Street 1:5447 E BEAUMONT CENTER BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5210
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-25
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician