Provider Demographics
NPI:1689818379
Name:SHANNON K WALISER LICSW MPA LLC DBA MIND BODY WELLNESS
Entity Type:Organization
Organization Name:SHANNON K WALISER LICSW MPA LLC DBA MIND BODY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:KRISTI
Authorized Official - Last Name:WALISER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, MPA, LICSW
Authorized Official - Phone:304-363-4265
Mailing Address - Street 1:PO BOX 1286
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-1286
Mailing Address - Country:US
Mailing Address - Phone:304-363-4265
Mailing Address - Fax:
Practice Address - Street 1:295 HIGH ST STE 3
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-5449
Practice Address - Country:US
Practice Address - Phone:304-363-4265
Practice Address - Fax:304-999-4826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009425211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9382141Medicare PIN