MEDICARE: MRS. TERRI ANIKA WILSON MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1003251695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERRI ANIKA WILSON MS

Provider Business Mailing Address
First Line	:	91-1050 MAKAIKE ST
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-5113
Country	:	US
Telephone Number	:	808-664-5948
Fax Number	:	334-543-0961

Provider Business Practice Location Address
First Line	:	91-1050 MAKAIKE ST
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-5113
Country	:	US
Telephone Number	:	808-664-5948
Fax Number	:	334-543-0961

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2013
Last Update Date	:	11/09/2020

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