Healthcare Provider Details

I. General information

NPI: 1083402200
Provider Name (Legal Business Name): SHAMBA WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 GUST LN
CHESAPEAKE VA
23323-2930
US

IV. Provider business mailing address

1332 GUST LN
CHESAPEAKE VA
23323-2930
US

V. Phone/Fax

Practice location:
  • Phone: 757-270-0526
  • Fax:
Mailing address:
  • Phone: 757-270-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: