Provider Demographics
NPI:1972379477
Name:WILSON, DESHAWN (LMT)
Entity type:Individual
Prefix:
First Name:DESHAWN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:DESHAWN
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:484 S ROXBURY DR APT 305
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4101
Mailing Address - Country:US
Mailing Address - Phone:310-402-7430
Mailing Address - Fax:
Practice Address - Street 1:484 S ROXBURY DR APT 305
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4101
Practice Address - Country:US
Practice Address - Phone:310-402-7430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6740225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist