Provider Demographics
NPI:1346694700
Name:WILSON, KHIANTI M
Entity Type:Individual
Prefix:
First Name:KHIANTI
Middle Name:M
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 1:4996 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70127-3114
Mailing Address - Country:US
Mailing Address - Phone:504-259-5342
Mailing Address - Fax:
Practice Address - Street 1:3308 TULANE AVE STE 407
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7158
Practice Address - Country:US
Practice Address - Phone:504-821-6830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251500000X104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker