Healthcare Provider Details

I. General information

NPI: 1043134950
Provider Name (Legal Business Name): SHALONDA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 AZALEA DR
SOMERVILLE TN
38068-6917
US

IV. Provider business mailing address

10077 WOODLEE CV
CORDOVA TN
38016-0367
US

V. Phone/Fax

Practice location:
  • Phone: 901-467-7847
  • Fax:
Mailing address:
  • Phone: 901-467-7847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9016
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: