Provider Demographics
NPI:1467701136
Name:WILSON, SHAANA D
Entity type:Individual
Prefix:MS
First Name:SHAANA
Middle Name:D
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 1:1307 APOLLO BEACH BLVD S UNIT 101
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-3092
Mailing Address - Country:US
Mailing Address - Phone:813-410-7025
Mailing Address - Fax:
Practice Address - Street 1:1307 APOLLO BEACH BLVD S UNIT 101
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-3092
Practice Address - Country:US
Practice Address - Phone:813-410-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120613000Medicaid
FL010658700Medicaid