Provider Demographics
NPI:1669518528
Name:WILKERSON, SANDRA FRANK (MA)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:FRANK
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4237 S PIPKIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-1442
Mailing Address - Country:US
Mailing Address - Phone:863-701-2470
Mailing Address - Fax:863-668-4091
Practice Address - Street 1:1437 S BELCHER RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-2829
Practice Address - Country:US
Practice Address - Phone:727-524-4464
Practice Address - Fax:727-538-7272
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10700101YA0400X
FLMT 2051106H00000X
TX201283106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766534200Medicaid