Provider Demographics
NPI:1164393716
Name:WILSON, TANITIA
Entity type:Individual
Prefix:
First Name:TANITIA
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 1:693 REINHARD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2937
Mailing Address - Country:US
Mailing Address - Phone:614-226-5040
Mailing Address - Fax:
Practice Address - Street 1:2300 S HAMILTON RD STE C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4477
Practice Address - Country:US
Practice Address - Phone:614-556-5107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator