Provider Demographics
NPI:1245890979
Name:ROBINSON, SHELLIE MARIE WILSON
Entity type:Individual
Prefix:
First Name:SHELLIE
Middle Name:MARIE WILSON
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLIE
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2743 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-2417
Mailing Address - Country:US
Mailing Address - Phone:417-300-8001
Mailing Address - Fax:
Practice Address - Street 1:2743 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2417
Practice Address - Country:US
Practice Address - Phone:417-300-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YM0800X
MO2019031206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO678427847OtherHPSO