=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164067534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DA'MEON SHERELL WILKES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2019
-----------------------------------------------------
Last Update Date | 10/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9890 COUNTY FARM RD STE 2
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-3678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-509-2499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12082 CLARK ST APT 206
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92557-8665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-207-6101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 92814
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 92814
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------