Healthcare Provider Details

I. General information

NPI: 1114984077
Provider Name (Legal Business Name): LITASHA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SUNNYBROOK RD
RALEIGH NC
27610-1855
US

IV. Provider business mailing address

5309 TALISON CT
RALEIGH NC
27610-2163
US

V. Phone/Fax

Practice location:
  • Phone: 919-212-3011
  • Fax: 919-255-1541
Mailing address:
  • Phone: 919-212-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004473
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: