Healthcare Provider Details

I. General information

NPI: 1467701136
Provider Name (Legal Business Name): MS. SHAANA D WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 APOLLO BEACH BLVD S UNIT 101
APOLLO BEACH FL
33572-3092
US

IV. Provider business mailing address

1307 APOLLO BEACH BLVD S UNIT 101
APOLLO BEACH FL
33572-3092
US

V. Phone/Fax

Practice location:
  • Phone: 813-410-7025
  • Fax:
Mailing address:
  • Phone: 813-410-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: