Provider Demographics
NPI:1164182135
Name:WILSON, SHANE (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LMHC
Mailing Address - Street 1:7777 SW 86 ST BLDG F1
Mailing Address - Street 2:APT 212
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143
Mailing Address - Country:US
Mailing Address - Phone:786-444-1735
Mailing Address - Fax:
Practice Address - Street 1:7777 SW 86 ST BLDG F1
Practice Address - Street 2:APT 212
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143
Practice Address - Country:US
Practice Address - Phone:786-444-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health