Provider Demographics
NPI:1518331362
Name:WILKERSON, SHANNON RENARD (EDD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:RENARD
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 STRICKLAND ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1261
Mailing Address - Country:US
Mailing Address - Phone:678-838-8333
Mailing Address - Fax:678-838-8444
Practice Address - Street 1:6311 STRICKLAND ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1261
Practice Address - Country:US
Practice Address - Phone:678-838-8333
Practice Address - Fax:678-838-8444
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009455101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor