Healthcare Provider Details

I. General information

NPI: 1386228187
Provider Name (Legal Business Name): MARSHA WILSON AT HOME RESIDENTIAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 LEMON AVE
KISSIMMEE FL
34746-3710
US

IV. Provider business mailing address

1890 LEMON AVE
KISSIMMEE FL
34746-3710
US

V. Phone/Fax

Practice location:
  • Phone: 407-970-3909
  • Fax: 407-201-5987
Mailing address:
  • Phone: 407-970-3909
  • Fax: 407-201-5987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MARSHA ANTHIA WILSON
Title or Position: OWNER
Credential: MSW, CDP, MS-ED
Phone: 407-970-3909