MEDICARE: SHAYLA 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	103K00000X	Behavior Analyst		FL

General Provider Information

NPI Number	:	1619452141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAYLA WILSON

Provider Business Mailing Address
First Line	:	1030 WINDMILL GROVE CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-7238
Country	:	US
Telephone Number	:	321-217-2797
Fax Number	:

Provider Business Practice Location Address
First Line	:	1160 S SEMORAN BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32807-1461
Country	:	US
Telephone Number	:	407-801-9924
Fax Number	:

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

Provider Enumeration Date	:	10/01/2018
Last Update Date	:	10/01/2018

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Directions to “ SHAYLA WILSON ” Practice Location

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