Provider Demographics
NPI:1396225843
Name:WILSON, SHANNON A (RBT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 QUARRY HEIGHTS WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-1080
Mailing Address - Country:US
Mailing Address - Phone:443-386-1882
Mailing Address - Fax:815-301-8671
Practice Address - Street 1:2733 QUARRY HEIGHTS WAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-1080
Practice Address - Country:US
Practice Address - Phone:443-386-1882
Practice Address - Fax:815-301-8671
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician