Provider Demographics
NPI:1700544202
Name:WILSON, TALAYSIA LOVETTE (CDCA)
Entity Type:Individual
Prefix:
First Name:TALAYSIA
Middle Name:LOVETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1809
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43216-1809
Mailing Address - Country:US
Mailing Address - Phone:614-225-0990
Mailing Address - Fax:614-225-0991
Practice Address - Street 1:16 W LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2815
Practice Address - Country:US
Practice Address - Phone:614-225-0990
Practice Address - Fax:614-225-0991
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
OHCDCA.179007101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator