MEDICARE: LAKEISHA WILSON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	13438-R	CA

General Provider Information

NPI Number	:	1134762081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEISHA WILSON

Provider Business Mailing Address
First Line	:	3575 SAN PABLO DAM RD STE 100
Second Line	:
City	:	EL SOBRANTE
State	:	CA
Zip	:	94803-7203
Country	:	US
Telephone Number	:	510-396-2879
Fax Number	:

Provider Business Practice Location Address
First Line	:	3575 SAN PABLO DAM RD STE 100
Second Line	:
City	:	EL SOBRANTE
State	:	CA
Zip	:	94803-7203
Country	:	US
Telephone Number	:	510-396-2879
Fax Number	:

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

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	10/23/2019

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Directions to “ LAKEISHA WILSON ” Practice Location

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