Healthcare Provider Details

I. General information

NPI: 1710534151
Provider Name (Legal Business Name): KEANYA WILSON MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. KEANYA CARR

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 1ST ST NE
WASHINGTON DC
20002-3361
US

IV. Provider business mailing address

1200 1ST ST NE
WASHINGTON DC
20002-3361
US

V. Phone/Fax

Practice location:
  • Phone: 202-276-3911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18846
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50082179
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number256683
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: