Healthcare Provider Details

I. General information

NPI: 1497050272
Provider Name (Legal Business Name): TANISHA RENEE WILSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 HIGH ST STE 101
MEDFORD MA
02155-3800
US

IV. Provider business mailing address

5 HIGH ST STE 101
MEDFORD MA
02155-3800
US

V. Phone/Fax

Practice location:
  • Phone: 781-338-2640
  • Fax: 781-338-2217
Mailing address:
  • Phone: 781-333-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12401-MH-CC
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: