Provider Demographics
NPI:1801550983
Name:WILSON, TASHA MONIQUE
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:MONIQUE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TASHA
Other - Middle Name:MONIQUE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:955 W CENTER ST STE 12B
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-7327
Mailing Address - Country:US
Mailing Address - Phone:209-407-1090
Mailing Address - Fax:
Practice Address - Street 1:955 W CENTER ST STE 12A
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-7327
Practice Address - Country:US
Practice Address - Phone:209-239-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)