Provider Demographics
NPI:1184719270
Name:WILSON, SHANNA LEIGH (LMFT)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W TEFFT ST UNIT 901
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-7048
Mailing Address - Country:US
Mailing Address - Phone:559-307-6713
Mailing Address - Fax:
Practice Address - Street 1:630 W TEFFT ST UNIT 901
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-7048
Practice Address - Country:US
Practice Address - Phone:559-307-6713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT42905106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist