Healthcare Provider Details

I. General information

NPI: 1659906212
Provider Name (Legal Business Name): KEISHA WILSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6573 KINGS BRANCH DR N
MOBILE AL
36618-4697
US

IV. Provider business mailing address

6573 KINGS BRANCH DR N
MOBILE AL
36618-4697
US

V. Phone/Fax

Practice location:
  • Phone: 251-406-1752
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number0099-8484
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number46493
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: