Provider Demographics
NPI:1013225754
Name:WILSON, SHANNON AMBER (LMSW)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:AMBER
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 1/2 W MICHIGAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1556
Mailing Address - Country:US
Mailing Address - Phone:269-753-4826
Mailing Address - Fax:
Practice Address - Street 1:215 E GREEN ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1534
Practice Address - Country:US
Practice Address - Phone:269-248-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490151911041C0700X
MEMC126201041C0700X
MI68010918141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical