Provider Demographics
NPI:1700683026
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 1:2440 WISTERIA DR UNIT 769
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-1967
Mailing Address - Country:US
Mailing Address - Phone:770-744-1740
Mailing Address - Fax:
Practice Address - Street 1:2775 CRUSE RD STE 601
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7142
Practice Address - Country:US
Practice Address - Phone:770-744-1740
Practice Address - Fax:770-759-1009
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health