Provider Demographics
NPI:1104021534
Name:WILSON, NISHA
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:
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:PO BOX 558
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0558
Mailing Address - Country:US
Mailing Address - Phone:918-207-3031
Mailing Address - Fax:918-207-3064
Practice Address - Street 1:1400 HENSLEY DR
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5221
Practice Address - Country:US
Practice Address - Phone:918-207-3031
Practice Address - Fax:918-207-3064
Is Sole Proprietor?:No
Enumeration Date:2007-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health