Provider Demographics
NPI:1750126470
Name:WILSON, ISHALON SHANQUELL SIEDAH (LMHC)
Entity type:Individual
Prefix:
First Name:ISHALON
Middle Name:SHANQUELL SIEDAH
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:ISHA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:4090 SW JAQUST ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5626
Mailing Address - Country:US
Mailing Address - Phone:850-631-0977
Mailing Address - Fax:
Practice Address - Street 1:4090 SW JAQUST ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5626
Practice Address - Country:US
Practice Address - Phone:850-631-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23967101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health