Provider Demographics
NPI:1013225754
Name:WILSON, SHANNON AMBER (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:AMBER
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 ROYAL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8213
Mailing Address - Country:US
Mailing Address - Phone:269-753-4826
Mailing Address - Fax:
Practice Address - Street 1:3535 N CALIFORNIA AVE
Practice Address - Street 2:SUITE F
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-1178
Practice Address - Country:US
Practice Address - Phone:309-686-2153
Practice Address - Fax:888-371-6976
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC126201041C0700X
IL1490151911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical