Provider Demographics
NPI:1407122617
Name:DICKENS, SHANNA (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:
Last Name:DICKENS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 SOFT SKY LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-5831
Mailing Address - Country:US
Mailing Address - Phone:910-526-0550
Mailing Address - Fax:
Practice Address - Street 1:3001 WRIGHTSVILLE AVE STE B
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4106
Practice Address - Country:US
Practice Address - Phone:910-526-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-02
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0076921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical