Provider Demographics
NPI:1437637733
Name:WIGGINS, SHANNON S (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:S
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 RAVENHILL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5460
Mailing Address - Country:US
Mailing Address - Phone:910-708-6025
Mailing Address - Fax:
Practice Address - Street 1:2545 RAVENHILL DR STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5460
Practice Address - Country:US
Practice Address - Phone:910-708-6025
Practice Address - Fax:910-858-5876
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0151671041C0700X
NCP0128241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical