MEDICARE: LITASHA WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C004473	NC

General Provider Information

NPI Number	:	1114984077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LITASHA WILSON

Provider Business Mailing Address
First Line	:	5309 TALISON CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-2163
Country	:	US
Telephone Number	:	919-212-1065
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 SUNNYBROOK RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-1855
Country	:	US
Telephone Number	:	919-212-3011
Fax Number	:	919-255-1541

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	07/08/2007

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Directions to “ LITASHA WILSON ” Practice Location

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