Provider Demographics
NPI:1013396175
Name:WILSON, SHANNON L (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
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 1:90 HOPE DR BLDG 6000
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1062
Mailing Address - Country:US
Mailing Address - Phone:208-288-7580
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1062
Practice Address - Country:US
Practice Address - Phone:208-288-7580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-33063104100000X
IDLCSW-364021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker