Provider Demographics
NPI:1356684153
Name:WILSON, SHALAYA VE'NETTA
Entity type:Individual
Prefix:
First Name:SHALAYA
Middle Name:VE'NETTA
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 1:411 HOBRON LN APT 3013
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-1217
Mailing Address - Country:US
Mailing Address - Phone:702-272-5183
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 185
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5006
Practice Address - Country:US
Practice Address - Phone:702-272-5183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty