Provider Demographics
NPI:1902572308
Name:WILSON, SHIVA
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 CRANE ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4253
Mailing Address - Country:US
Mailing Address - Phone:650-326-5888
Mailing Address - Fax:
Practice Address - Street 1:1225 CRANE ST STE 205
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4253
Practice Address - Country:US
Practice Address - Phone:650-394-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132296101YM0800X
101YM0800X
CA11538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health