Provider Demographics
NPI:1083755367
Name:WILLMON, SHIRLEY (LPC)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:WILLMON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2033
Mailing Address - Country:US
Mailing Address - Phone:417-448-1756
Mailing Address - Fax:
Practice Address - Street 1:1500 W ASHLAND ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-1710
Practice Address - Country:US
Practice Address - Phone:417-667-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006030458101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493744502Medicaid