Provider Demographics
NPI:1659145605
Name:WILSON, QUEEN VALENCIA
Entity Type:Individual
Prefix:
First Name:QUEEN
Middle Name:VALENCIA
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 1:3763 BELLEAU ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-4419
Mailing Address - Country:US
Mailing Address - Phone:901-319-6714
Mailing Address - Fax:
Practice Address - Street 1:1088 ROGERS RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-8546
Practice Address - Country:US
Practice Address - Phone:901-755-1396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health