Provider Demographics
NPI:1992371421
Name:WILSON, NAKEISHA SHAUNTA
Entity type:Individual
Prefix:
First Name:NAKEISHA
Middle Name:SHAUNTA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14006 SAPPHIRE PARK LN APT 303
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5322
Mailing Address - Country:US
Mailing Address - Phone:804-255-6677
Mailing Address - Fax:
Practice Address - Street 1:2820 WATERFORD LAKE DR STE 102
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3994
Practice Address - Country:US
Practice Address - Phone:804-658-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician