Provider Demographics
NPI:1093198715
Name:WILSON, SHONDA (LCSW-A)
Entity Type:Individual
Prefix:MISS
First Name:SHONDA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 COMMERCE PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7386
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:910-775-9165
Practice Address - Street 1:402 N PINE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-5563
Practice Address - Country:US
Practice Address - Phone:910-739-1666
Practice Address - Fax:910-739-6822
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0097211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04061981Medicaid
NC04061981Medicare UPIN
NC04061981Medicare Oscar/Certification
NC04061981Medicaid
NC0406198100Medicare NSC