Provider Demographics
NPI:1013704071
Name:WILSON, LATOYA SHENA
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:SHENA
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 QUEEN PIERRETTE ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-8706
Mailing Address - Country:US
Mailing Address - Phone:336-268-5127
Mailing Address - Fax:336-268-5127
Practice Address - Street 1:4761 QUEEN PIERRETTE ST.
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-8706
Practice Address - Country:US
Practice Address - Phone:336-268-5127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0213411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical