Provider Demographics
NPI:1134762081
Name:WILSON, LAKEISHA
Entity type:Individual
Prefix:
First Name:LAKEISHA
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 1:3575 SAN PABLO DAM RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-7203
Mailing Address - Country:US
Mailing Address - Phone:510-396-2879
Mailing Address - Fax:
Practice Address - Street 1:3575 SAN PABLO DAM RD STE 100
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-7203
Practice Address - Country:US
Practice Address - Phone:510-396-2879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13438-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)