Provider Demographics
NPI:1477245314
Name:WILSON, KEISHA SHARONDA
Entity Type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:SHARONDA
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 1:336 SPRAGUE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5626
Mailing Address - Country:US
Mailing Address - Phone:336-412-1968
Mailing Address - Fax:
Practice Address - Street 1:2479 ALOMA AVE UNIT D
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2541
Practice Address - Country:US
Practice Address - Phone:407-657-6692
Practice Address - Fax:407-894-6010
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health