Provider Demographics
NPI:1194398537
Name:WILSON, ALEISHA MARIE
Entity Type:Individual
Prefix:
First Name:ALEISHA
Middle Name:MARIE
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 1:3016 POLAR LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3031
Mailing Address - Country:US
Mailing Address - Phone:512-807-0551
Mailing Address - Fax:
Practice Address - Street 1:3016 POLAR LN
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3031
Practice Address - Country:US
Practice Address - Phone:512-807-0551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician