Provider Demographics
NPI:1609426543
Name:WILSON, SHANE' ROLANDA
Entity type:Individual
Prefix:
First Name:SHANE'
Middle Name:ROLANDA
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 1:5121 KINGDOM WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5121 KINGDOM WAY STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6063
Practice Address - Country:US
Practice Address - Phone:919-743-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2024-11-04
Deactivation Date:2023-10-14
Deactivation Code:
Reactivation Date:2023-10-23
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
NC1447103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician