Healthcare Provider Details

I. General information

NPI: 1649104746
Provider Name (Legal Business Name): QUINETTA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W THIRD ST
MEDIA PA
19063-2401
US

IV. Provider business mailing address

105 W THIRD ST
MEDIA PA
19063-2401
US

V. Phone/Fax

Practice location:
  • Phone: 267-587-6722
  • Fax:
Mailing address:
  • Phone: 267-587-6722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: