Healthcare Provider Details

I. General information

NPI: 1619468055
Provider Name (Legal Business Name): TINASHIA WILKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 HIGHWAY 160 W STE 240
FORT MILL SC
29708-8035
US

IV. Provider business mailing address

1698 HIGHWAY 160 W STE 240
FORT MILL SC
29708-8035
US

V. Phone/Fax

Practice location:
  • Phone: 704-654-8599
  • Fax:
Mailing address:
  • Phone: 704-654-8599
  • Fax: 336-642-0384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-31333
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-40036
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: