Provider Demographics
NPI:1467989806
Name:WILSON, SHANTA NICOLE (LPC, LPC-MHSP, NCC)
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC, LPC-MHSP, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8787 LEGACY DR APT 1480
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-2545
Mailing Address - Country:US
Mailing Address - Phone:901-218-4688
Mailing Address - Fax:
Practice Address - Street 1:868 N MANASSAS ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38107-2516
Practice Address - Country:US
Practice Address - Phone:901-577-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3708101YM0800X
TX80044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health